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Use of a ureteral Pacemaker in the Treatment of Ureteral Reflux
Vol. 95, Feb. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1966 by The Williams & Wilkins Co.
USE OF A URETERAL PACEMAKER IN THE TREAT:.VIENT OF URETERAL REFLUX W. F. MELICK, A. E. BRODEUR, F. HERBIG
AND
J. J. NARYKA
From the Departments of Urology, Radiology anclinternal Medicine, St. Louis University School of Medicine ancl the Cardinal Glennon Memorial Hospital for Children, St. Louis, Missouri
For a number of years we have been interested in the mechanis1ns of the refluxing ureter. vVe have seen a number of patients who have failed to do well following anti-reflux procedures, our own cases as well as cases done elsewhere. This fact has convinced us that none of the presently known surgical methods provides a satisfactory approach for all cases. We believe that one should speak guardedly of cure whenever ureteral reflux has been arrested. We are convinced that many of the current operative procedures may arrest reflux at the expense of impeding efflux and fail to restore normal tone to the ureter. In the years following, further kidney dilation and ultimate renal damage may ensue. Kiil first suggested using the strain gauge to measure intraureteral pressures1 and its use has been reported. 2- 5 Many years ago severe reflux was treated by simple suprapubic drainage. While improvement was noted in some patients, the catheter is a foreign body and its presence certainly potentiates infection. New techniques of cutaneous vesicostomy provided a way of urinary diversion without a catheter. From a simple mechanical viewpoint, cutaneous vesicosAccepted for publication July 9, 1965. Read at annual meeting of The Society for Pediatric Urology on May 9, 1965, held in conjunction with convention of American Urological Association, Inc., New Orleans, Louisiana, May 10-13, 1965. Supported in part by grant HD-00660-14SI from the National Institutes of Health, United States Public Health Service. 1 Kiil, F.: The Function of The Ureter and Renal Pelvis. Philadelphia: W. B. Saunders Co., 1957. 'Melick, W. F. and Naryka, J. J.: Pressure studies of the normal and abnormal ureter in children by means of the strain gauge. J. Urol., 83: 267, 1960. 3 lVIurnaghan, G. F.: Experimental investigation of the dynamics of the normal and dilated ureter. Brit. J. Urol., 29: 403, 1957. 4 Davis, D. M., Zimskind, P. D. and Paquet, J. P.: Studies on urodynamics: new light on ureteral function. J. Urol., 90: 150, 1963. 5 Boyarsky, S., Martinez, J., Elkin, M. and Goldenberg, J.: Integration of renal and ureteral function by intraluminal pressure. J.A.JVI.A., 183 : 434, 1963.
tomy does away with ureteral backpressure on voiding. It prevents any accunrnlation which would impede the passage of more urine down the ureter. There are mechanical and technical complications which may prevent vesicostomy from accomplishing its purpose but these are relatively easy to detect. We are presenting a study of such a procedure. JVI. H., a 7-month-old boy, was first seen in 1962 because of failure to develop normally and to gain weight. Diagnostic study showed an elevated blood urea nitrogen and marked bilateral ureterorenal reflux (fig. 1) . The ureteral pressure recordings failed to reveal any ureteral pressure waves, although during cine-cystograms seemingly active peristaltic waves were seen. We have commented on this previously and do not believe that peristaltic activity can be assumed to be normal because waves are seen during cine examinations. 6 Cutaneous vesicostomy was done at this time and subsequent checks at monthly intervals insured that the stoma remained wide and that there never was any appreciable residual urine. The urinary infection improved but did not completely disappear. A year later no reflm, could be demonstrated on the right side but it was still noted on the left side. Two and one-half years later there was still no demonstrable right ureteral reflux but there was intermittent left ureteral reflux. An examination made by occluding the vesicostomy with a partially inflated Foley catheter did not show reflux on either side (fig. 2). However, a week later a sin1ilar examination showed left ureteral reflux. Presently, right ureteral pressures have returned to normal levels and the waves appear with normal frequency. However, on the left side there has been improvement but the pressure levels and frequency are below normal values 6 Melick, W. F., Brodeur, A. E. and Karellos, D. N.: A suggested classification of ureteral reflux and suggested treatment based on cineradiographic findings and simultaneous pressure recordings by means of the strain gauge. J. Urol., 88: 35, 1962.
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FIG. 1. M. H. A, voiding cystourethrogram; note marked bilateral ureteral reflux. B, renal reflux is demonstrated. C, relatively normal 6-minute excretory urogram; ureteral pressures were so low they could not be recorded.
FIG. 2. M. H. A, no reflux on right but left reflux is still present after 1 year of continuous drainage by cutaneous vesicostomy. B, after 2~-6 years of continuous drainage by cutaneous vesicostomy there was no reflux. Subsequent films show intermittent left reflux. C, right pelvic and upper ureteral pressures are normal after 2~,i years of drainage. (fig. 3). Since no operative procedures have been done on either ureterovesical juncture, it would seem that simple rest has allowed the right ureteral muscle bundles to return to norn1al. The
left ureteral muscle bundles have been improved but have not recovered entirely normal tone and ~till show intermittent reflux. One can only speculate as to why one ureter
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FIG. 3. M. H. A, mid and lower ureteral pressures on right 2~:2 years after cutaneous vesicostomy. B, left upper and mid ureteral pressures measured simultaneously. Markedly deficient compared to normal right ureteral pressures but now definitely present.
has regained normal tone and the other has only partially regained it. In an effort to increase muscle tone we turned to the possibility of electrical stimulation. In a previous study we found that it was possible to reverse a segment of pig ureter and have it work normally. 7 Thus there seems little evidence of extrinsic nerve innervation in ureteral peristalsis. In working with hydronephrotic pig ureters we found it possible to stimulate them anywhere along the course of the ureter. If there is a nodal point of stimulation, such as exists in the heart, we were unable to locate such a point. Prolonged electrical stimulation of the pig ureter with currents up to 7 Melick, W. F., Naryka, J. J. and Schmidt, J. H.: Experimental studies of ureteral peristaltic
patterns in the pig. II. Myogenic activity of the pig ureter. J. Urol., 86: 46, 1961.
12 volts did not produce any scarring. Monitoring with continuous electrocardiography produced no abnormalities suggestive of danger to the cardiac system. Top voltages did occasionally produce skeletal muscle contractions which in human patients did not prove to be painful; however, they were occasionally frightening to the child until explained. For the first clinical trial we decided to select a child who had failed to respond to long rest periods and who had not had any anti-reflux procedures on the ureterovesical junctures. E. S., a 13-month-old girl, was first seen in November 1959. She was admitted to Glennon Hospital because of failure to gain weight and repeated episodes of urinary infection. Cystograms showed marked bilateral reflux and almost no demonstrable ureteral pressures (fig. 4). A Y-V plasty
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187
Fm. 4. E. S. A,'rii~ssiv~ bilateral ureterorenal reflux when first seen. B, markedly low pressure, infrequent peristaltic waves seen in right ureter at this time.
of the bladder neck and a suprapubic cystostomy were done. Careful periodic cine examinations showed the reflux still present whenever the tube was clamped. A representative finding 3 years postoperatively is shown in figure 5. In May 1964 re-evaluation still showed bilateral massive reflux when the suprapubic tube was clamped and there were almost no measurable ureteral pressures. On May 27, through a small lumbar incision and using standard cardiac wires, a ground wire was placed on the right renal capsule and the active electrode on the upper part of the right ureter. An external type of pacemaker was built so that stimulating current duration and voltage could be changed whenever desirable. The following perimeters were used: voltage, 4 to 9 volts; diphasic current (monophasic burns ureter); in-
terval between stimulation, 10 to 30 seconds; square wave form; duration of train, 0.4 seconds; duration of individual stimuli, 1 millist1cond and interval between individual stimuli, from 5 to 10 milliseconds. This proved to give the longest battery life. Weekly monitoring with an osc.illoscope proved necessary to be certain stimulation was being maintained at the desired levels. The stimulator was placed in a cloth bag and worn around the patient's waist. Reflux was still present a week after beginning constant electrical stimulation. During .the second week a cystogram was done with barium and to our consternation it entered the renal parenchyma. This led to a study of barium cystography in pigs and we found that the procedure could be reproduced readily. Renal biopsies on the pigs
FIG. 5. E. S., after 3 years of continuous suprapubic drainage massive bilateral ureterorenal reflux still occurs when tube is clamped.
FIG. 6. E. S. A, after 1 week of stimulation with pacemaker reflux still present. B, after 1 month reflux has stopped on right, still present on left. C, 3 weeks after pacemaker stopped reflux seen in right ureter to point of stimulation. D, 1 week later no reflux seen on right.
188
FrG. 7. E. S. A, no reflux 5 months after pacemaker stopped and 4 months after removal of suprapubic tube. B, ureteral pressure recordings, right upper ureter with pacemaker stimulation. C, normal peristaltic pressure patterns continue after stimulator is turned off.
Fm. 8. J. P. A, initial findings, massive reflux returned after previous anti-reflux procedures. B, pacemaker in position, some improvement in size in region of ureteropelvic juncture. C, 2 months after continuous stimulation, ureter is smaller in size but reflux is still present.
mo
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Frn. 9. J.P. A, simultaneous recording of filling bladder pressure and right ureteral pres.sure. Poor ureteral wave pressure patterns. B, after -reflux pressures in ureter and bladder equalize;note pattern when crying, equal pressure pattern spikes seen.
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Fm. 10. J.P., effect on ureteral peristalsis of increasing voltage from 3 to 9 volts. Increasing frequency of peristalsis and increasing ureteral pressure are seen at 9 volts. where barium entered the renal parenchyma revealed intense foreign body reaction. We feel that the use of barium should be abandoned. 8 Three weeks after pacing began on this patient there was no reflux on the right side (fig. 6). Three months later the reflux: had stopped and the right ureteral pressures were normal. The pressure waves in the right ureter remained normal when the stimulator was turned off and examinations over the next 5 months showed no reflux (fig. 7). The suprapubic tube was removed 1 8 Brodeur, A. E., Goyer, R. and Melick, W. F.: Potential hazards of barium cystography. Submitted for publication.
month after the pacemaker was discontinued and reflux was still absent. Eleven months later there was slight reflux in the previously stimulated ureter but only at the end of voiding. A pacemaker was next used in J.P., an 11-yearold child sent to us by Dr. Edgar Slotkin. The child had undergone revision of the bladder neck and later a transurethral resection of the bladder neck. The parents refused to consider any form of urinary diversion. The initial cine findings showed massive bilateral ureterorenal reflux with tremendously dilated ureters (fig. 8). Pressure studies done on November 9, 1964 showed early reflux, first on the right and then on the left
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Fm. 11. J. P., after 2 months of continuous electrical stimulation, right ureter shows occasional regularity. Left ureter shows no appreciable pressure waves.
side. Simultaneous intravesical and right ureteral pressure studies showed, as could be e:iqiected, equalization of pressures in the bladder and right ureter after reflux occurred. Very low pressures were recorded in both ureters with no normal wave patterns. Again what appeared as good peristaltic waves on cine studies proved to have no appreciable pressures (fig. 9). Pacemaker stimulation was started using the renal capsule as a ground and the active lead was put on the right ureteropelvic juncture. It was necessary to increase the voltage to 9 volts to effect stimulation (fig. 10). At this level we were able to maintain fairly regular waves, but unfortunately not very normal pressures. After 2 months of constant stimulation the right ureter showed occasional regularity and definite but lower than normal pressure waves. The unpaced left ureter was unchanged and no appreciable waves were seen (fig. 11). When stimulation was discontinued the right ureteral pressures began to drop and within a few minutes were completely lost (fig. 12). The third child, C. B., was a 2-year-old girl first seen in April 1961 because of recurrent urinary infection during the preceding year. Cine
cystograms at this time showed a bilateral ureterorenal reflux with bilaterally dilated ureters and kidneys. A Y-V plasty and a suprapubic cystostomy were done. As in the first case reported, massive reflux persisted whenever the suprapubic tube was clamped (fig. 13). Measurements of the ureteral pressures showed irregularity of peristalsis and poor pressure levels. Wires were placed on the right renal capsule and ureteropelvic juncture on January 5, 1965 and constant stimulation was started. At this time massive reflux was still present. Three weeks later there was ureteral reflux but no renal reflux. Six weeks later right renal reflux was again demonstrated (fig. 14). After 2H months of constant stimulation there was no demonstrable reflux and the stimulation was discontinued. A week later the ureteral pressure levels and frequency were normal throughout the entire ureter (fig. 15). The suprapubic tube was removed and examination 1 week and then 1 month later showed no reflux (fig. 16). DISCUSSION
Ureteral reflux certainly exists in many different forms. The effects of reflux upon the
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193
Fm. 12. J.P. A, when electrical stimulation is stopped right ureteral waves lose frequency and pressure patterns. B, pressure patterns disappear and frequency is diminished immediately.
urinary system vary from none to markedly severe dilation of the ureters and kidney pelves. Attempts have been made to correlate intravesical pressures with the severity of reflux. 6 • 9
Ureteral reflux which occurs during voiding or at the end of bladder fill and which produces no marked degree of anatomical distortion is almost
9 Lattimer, J. K., Apperson, J. W., Gleason, D. M., Baker, D. and Fleming, S.S.: The pressure
at which reflux occurs, an important indicator of prognosis and treatment. J. Urol., 89: 395, 1963.
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FIG. 13. C. B., reflux on clamping suprapubic tube after 2 years of continuous drainage.
always correctable by conservative measures or, much as we hate to use the term, the child "outgrows" it. There is a correlation between severe dilation and intraureteral pressure as measured by the strain gauge. However, in our opinion there is no correlation between what appears to be normal peristaltic activity seen on cine and ureteral pressure studies. The severely dilated ureters show little or no intraureteral pressure. The waves are irregular and do not show normal peristaltic forms. We have found, as in the first case reported (J\f. H.), that simple rest may restore ureteral tone and stop reflux, with no operative procedure at all on the ureterovesical juncture. There appeared to be no measurable difference between the 2 ureters in this case when first seen and we have no explanation of why rest failed to com-
Fm. 14. C. B. A, after 3 weeks of constant electrical stimulation there is still right ureteral reflux but none into kidney. B, 6 weeks later ureterorenal reflux present on right. C, 10 weeks later no demo11strable right renal reflux.
Fm. 15. C. B., ureteral peristaltic waves show normal pressures and frequency after discontinuing electrical stimulation.
Fm. 16. C. B. A and B, 1 week after removal of suprapubic tube and 2 weeks after stopping electrical stimulation no reflux noted. C and D, 4 weeks after removal of suprapubic tube and 5 weeks after stopping electrical stimulation no reflux noted.
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pletely restore the left ureteral tone. We may speculate that it will take a longer period of rest to do this. In the cases E. S. and C. B. ureteral pressures did not return with prolonged periods of rest. Pressures were restored by relatively brief periods-several months-of electrical stimulation. Both urinary tracts have now been restored to regular bladder voidings and its accompanying pressure relationships. vVe are well aware that what seems like a good result at present may not withstand the stress of the years to come. However, it should be pointed out that with technical improvements in our present crude stimulator one could be 1nade which could be buried and recharged from the outside, as is now possible with cardiac pacemakers. The case of J. P., while technically a failure, points out several interesting aspects of ureteral physiology. By increasing the voltage to 9 volts, which is the limit of our present device, consistent
with a workable battery life, it was possible to produce peristaltic waves which were regular in form and frequency. It was never possible to produce anything near the normal ureteral pressures of 18 to 20 mm. Hg. This child was much , older and had had reflux for years. This suggests that there may be a ureteral exhaustion point of no return, after which the ureteral muscle bundles are incapable of producing normal pressure levels. Many investigators have already applied this to our clinical thinking when we suggest "the last operation first," namely, urinary diversion on cases of severely dilated ureters. With cutaneous diversion and better forms of electronic stimulators it may be possible in the future to restore those patients in whom. the diagnosis is made early enough to a normal urinary system. 3720 ·washington Ave., St. Louis, M.issouri 63108 (W.F.M.)
THE JOURNAL OF UROLOGY
Copyright© 1966 by The Williams & Wilkins Co.
USE OF A URETERAL PACEMAKER IN THE TREAT:.VIENT OF URETERAL REFLUX W. F. MELICK, A. E. BRODEUR, F. HERBIG
AND
J. J. NARYKA
From the Departments of Urology, Radiology anclinternal Medicine, St. Louis University School of Medicine ancl the Cardinal Glennon Memorial Hospital for Children, St. Louis, Missouri
For a number of years we have been interested in the mechanis1ns of the refluxing ureter. vVe have seen a number of patients who have failed to do well following anti-reflux procedures, our own cases as well as cases done elsewhere. This fact has convinced us that none of the presently known surgical methods provides a satisfactory approach for all cases. We believe that one should speak guardedly of cure whenever ureteral reflux has been arrested. We are convinced that many of the current operative procedures may arrest reflux at the expense of impeding efflux and fail to restore normal tone to the ureter. In the years following, further kidney dilation and ultimate renal damage may ensue. Kiil first suggested using the strain gauge to measure intraureteral pressures1 and its use has been reported. 2- 5 Many years ago severe reflux was treated by simple suprapubic drainage. While improvement was noted in some patients, the catheter is a foreign body and its presence certainly potentiates infection. New techniques of cutaneous vesicostomy provided a way of urinary diversion without a catheter. From a simple mechanical viewpoint, cutaneous vesicosAccepted for publication July 9, 1965. Read at annual meeting of The Society for Pediatric Urology on May 9, 1965, held in conjunction with convention of American Urological Association, Inc., New Orleans, Louisiana, May 10-13, 1965. Supported in part by grant HD-00660-14SI from the National Institutes of Health, United States Public Health Service. 1 Kiil, F.: The Function of The Ureter and Renal Pelvis. Philadelphia: W. B. Saunders Co., 1957. 'Melick, W. F. and Naryka, J. J.: Pressure studies of the normal and abnormal ureter in children by means of the strain gauge. J. Urol., 83: 267, 1960. 3 lVIurnaghan, G. F.: Experimental investigation of the dynamics of the normal and dilated ureter. Brit. J. Urol., 29: 403, 1957. 4 Davis, D. M., Zimskind, P. D. and Paquet, J. P.: Studies on urodynamics: new light on ureteral function. J. Urol., 90: 150, 1963. 5 Boyarsky, S., Martinez, J., Elkin, M. and Goldenberg, J.: Integration of renal and ureteral function by intraluminal pressure. J.A.JVI.A., 183 : 434, 1963.
tomy does away with ureteral backpressure on voiding. It prevents any accunrnlation which would impede the passage of more urine down the ureter. There are mechanical and technical complications which may prevent vesicostomy from accomplishing its purpose but these are relatively easy to detect. We are presenting a study of such a procedure. JVI. H., a 7-month-old boy, was first seen in 1962 because of failure to develop normally and to gain weight. Diagnostic study showed an elevated blood urea nitrogen and marked bilateral ureterorenal reflux (fig. 1) . The ureteral pressure recordings failed to reveal any ureteral pressure waves, although during cine-cystograms seemingly active peristaltic waves were seen. We have commented on this previously and do not believe that peristaltic activity can be assumed to be normal because waves are seen during cine examinations. 6 Cutaneous vesicostomy was done at this time and subsequent checks at monthly intervals insured that the stoma remained wide and that there never was any appreciable residual urine. The urinary infection improved but did not completely disappear. A year later no reflm, could be demonstrated on the right side but it was still noted on the left side. Two and one-half years later there was still no demonstrable right ureteral reflux but there was intermittent left ureteral reflux. An examination made by occluding the vesicostomy with a partially inflated Foley catheter did not show reflux on either side (fig. 2). However, a week later a sin1ilar examination showed left ureteral reflux. Presently, right ureteral pressures have returned to normal levels and the waves appear with normal frequency. However, on the left side there has been improvement but the pressure levels and frequency are below normal values 6 Melick, W. F., Brodeur, A. E. and Karellos, D. N.: A suggested classification of ureteral reflux and suggested treatment based on cineradiographic findings and simultaneous pressure recordings by means of the strain gauge. J. Urol., 88: 35, 1962.
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FIG. 1. M. H. A, voiding cystourethrogram; note marked bilateral ureteral reflux. B, renal reflux is demonstrated. C, relatively normal 6-minute excretory urogram; ureteral pressures were so low they could not be recorded.
FIG. 2. M. H. A, no reflux on right but left reflux is still present after 1 year of continuous drainage by cutaneous vesicostomy. B, after 2~-6 years of continuous drainage by cutaneous vesicostomy there was no reflux. Subsequent films show intermittent left reflux. C, right pelvic and upper ureteral pressures are normal after 2~,i years of drainage. (fig. 3). Since no operative procedures have been done on either ureterovesical juncture, it would seem that simple rest has allowed the right ureteral muscle bundles to return to norn1al. The
left ureteral muscle bundles have been improved but have not recovered entirely normal tone and ~till show intermittent reflux. One can only speculate as to why one ureter
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FIG. 3. M. H. A, mid and lower ureteral pressures on right 2~:2 years after cutaneous vesicostomy. B, left upper and mid ureteral pressures measured simultaneously. Markedly deficient compared to normal right ureteral pressures but now definitely present.
has regained normal tone and the other has only partially regained it. In an effort to increase muscle tone we turned to the possibility of electrical stimulation. In a previous study we found that it was possible to reverse a segment of pig ureter and have it work normally. 7 Thus there seems little evidence of extrinsic nerve innervation in ureteral peristalsis. In working with hydronephrotic pig ureters we found it possible to stimulate them anywhere along the course of the ureter. If there is a nodal point of stimulation, such as exists in the heart, we were unable to locate such a point. Prolonged electrical stimulation of the pig ureter with currents up to 7 Melick, W. F., Naryka, J. J. and Schmidt, J. H.: Experimental studies of ureteral peristaltic
patterns in the pig. II. Myogenic activity of the pig ureter. J. Urol., 86: 46, 1961.
12 volts did not produce any scarring. Monitoring with continuous electrocardiography produced no abnormalities suggestive of danger to the cardiac system. Top voltages did occasionally produce skeletal muscle contractions which in human patients did not prove to be painful; however, they were occasionally frightening to the child until explained. For the first clinical trial we decided to select a child who had failed to respond to long rest periods and who had not had any anti-reflux procedures on the ureterovesical junctures. E. S., a 13-month-old girl, was first seen in November 1959. She was admitted to Glennon Hospital because of failure to gain weight and repeated episodes of urinary infection. Cystograms showed marked bilateral reflux and almost no demonstrable ureteral pressures (fig. 4). A Y-V plasty
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187
Fm. 4. E. S. A,'rii~ssiv~ bilateral ureterorenal reflux when first seen. B, markedly low pressure, infrequent peristaltic waves seen in right ureter at this time.
of the bladder neck and a suprapubic cystostomy were done. Careful periodic cine examinations showed the reflux still present whenever the tube was clamped. A representative finding 3 years postoperatively is shown in figure 5. In May 1964 re-evaluation still showed bilateral massive reflux when the suprapubic tube was clamped and there were almost no measurable ureteral pressures. On May 27, through a small lumbar incision and using standard cardiac wires, a ground wire was placed on the right renal capsule and the active electrode on the upper part of the right ureter. An external type of pacemaker was built so that stimulating current duration and voltage could be changed whenever desirable. The following perimeters were used: voltage, 4 to 9 volts; diphasic current (monophasic burns ureter); in-
terval between stimulation, 10 to 30 seconds; square wave form; duration of train, 0.4 seconds; duration of individual stimuli, 1 millist1cond and interval between individual stimuli, from 5 to 10 milliseconds. This proved to give the longest battery life. Weekly monitoring with an osc.illoscope proved necessary to be certain stimulation was being maintained at the desired levels. The stimulator was placed in a cloth bag and worn around the patient's waist. Reflux was still present a week after beginning constant electrical stimulation. During .the second week a cystogram was done with barium and to our consternation it entered the renal parenchyma. This led to a study of barium cystography in pigs and we found that the procedure could be reproduced readily. Renal biopsies on the pigs
FIG. 5. E. S., after 3 years of continuous suprapubic drainage massive bilateral ureterorenal reflux still occurs when tube is clamped.
FIG. 6. E. S. A, after 1 week of stimulation with pacemaker reflux still present. B, after 1 month reflux has stopped on right, still present on left. C, 3 weeks after pacemaker stopped reflux seen in right ureter to point of stimulation. D, 1 week later no reflux seen on right.
188
FrG. 7. E. S. A, no reflux 5 months after pacemaker stopped and 4 months after removal of suprapubic tube. B, ureteral pressure recordings, right upper ureter with pacemaker stimulation. C, normal peristaltic pressure patterns continue after stimulator is turned off.
Fm. 8. J. P. A, initial findings, massive reflux returned after previous anti-reflux procedures. B, pacemaker in position, some improvement in size in region of ureteropelvic juncture. C, 2 months after continuous stimulation, ureter is smaller in size but reflux is still present.
mo
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Frn. 9. J.P. A, simultaneous recording of filling bladder pressure and right ureteral pres.sure. Poor ureteral wave pressure patterns. B, after -reflux pressures in ureter and bladder equalize;note pattern when crying, equal pressure pattern spikes seen.
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Fm. 10. J.P., effect on ureteral peristalsis of increasing voltage from 3 to 9 volts. Increasing frequency of peristalsis and increasing ureteral pressure are seen at 9 volts. where barium entered the renal parenchyma revealed intense foreign body reaction. We feel that the use of barium should be abandoned. 8 Three weeks after pacing began on this patient there was no reflux on the right side (fig. 6). Three months later the reflux: had stopped and the right ureteral pressures were normal. The pressure waves in the right ureter remained normal when the stimulator was turned off and examinations over the next 5 months showed no reflux (fig. 7). The suprapubic tube was removed 1 8 Brodeur, A. E., Goyer, R. and Melick, W. F.: Potential hazards of barium cystography. Submitted for publication.
month after the pacemaker was discontinued and reflux was still absent. Eleven months later there was slight reflux in the previously stimulated ureter but only at the end of voiding. A pacemaker was next used in J.P., an 11-yearold child sent to us by Dr. Edgar Slotkin. The child had undergone revision of the bladder neck and later a transurethral resection of the bladder neck. The parents refused to consider any form of urinary diversion. The initial cine findings showed massive bilateral ureterorenal reflux with tremendously dilated ureters (fig. 8). Pressure studies done on November 9, 1964 showed early reflux, first on the right and then on the left
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Fm. 11. J. P., after 2 months of continuous electrical stimulation, right ureter shows occasional regularity. Left ureter shows no appreciable pressure waves.
side. Simultaneous intravesical and right ureteral pressure studies showed, as could be e:iqiected, equalization of pressures in the bladder and right ureter after reflux occurred. Very low pressures were recorded in both ureters with no normal wave patterns. Again what appeared as good peristaltic waves on cine studies proved to have no appreciable pressures (fig. 9). Pacemaker stimulation was started using the renal capsule as a ground and the active lead was put on the right ureteropelvic juncture. It was necessary to increase the voltage to 9 volts to effect stimulation (fig. 10). At this level we were able to maintain fairly regular waves, but unfortunately not very normal pressures. After 2 months of constant stimulation the right ureter showed occasional regularity and definite but lower than normal pressure waves. The unpaced left ureter was unchanged and no appreciable waves were seen (fig. 11). When stimulation was discontinued the right ureteral pressures began to drop and within a few minutes were completely lost (fig. 12). The third child, C. B., was a 2-year-old girl first seen in April 1961 because of recurrent urinary infection during the preceding year. Cine
cystograms at this time showed a bilateral ureterorenal reflux with bilaterally dilated ureters and kidneys. A Y-V plasty and a suprapubic cystostomy were done. As in the first case reported, massive reflux persisted whenever the suprapubic tube was clamped (fig. 13). Measurements of the ureteral pressures showed irregularity of peristalsis and poor pressure levels. Wires were placed on the right renal capsule and ureteropelvic juncture on January 5, 1965 and constant stimulation was started. At this time massive reflux was still present. Three weeks later there was ureteral reflux but no renal reflux. Six weeks later right renal reflux was again demonstrated (fig. 14). After 2H months of constant stimulation there was no demonstrable reflux and the stimulation was discontinued. A week later the ureteral pressure levels and frequency were normal throughout the entire ureter (fig. 15). The suprapubic tube was removed and examination 1 week and then 1 month later showed no reflux (fig. 16). DISCUSSION
Ureteral reflux certainly exists in many different forms. The effects of reflux upon the
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193
Fm. 12. J.P. A, when electrical stimulation is stopped right ureteral waves lose frequency and pressure patterns. B, pressure patterns disappear and frequency is diminished immediately.
urinary system vary from none to markedly severe dilation of the ureters and kidney pelves. Attempts have been made to correlate intravesical pressures with the severity of reflux. 6 • 9
Ureteral reflux which occurs during voiding or at the end of bladder fill and which produces no marked degree of anatomical distortion is almost
9 Lattimer, J. K., Apperson, J. W., Gleason, D. M., Baker, D. and Fleming, S.S.: The pressure
at which reflux occurs, an important indicator of prognosis and treatment. J. Urol., 89: 395, 1963.
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FIG. 13. C. B., reflux on clamping suprapubic tube after 2 years of continuous drainage.
always correctable by conservative measures or, much as we hate to use the term, the child "outgrows" it. There is a correlation between severe dilation and intraureteral pressure as measured by the strain gauge. However, in our opinion there is no correlation between what appears to be normal peristaltic activity seen on cine and ureteral pressure studies. The severely dilated ureters show little or no intraureteral pressure. The waves are irregular and do not show normal peristaltic forms. We have found, as in the first case reported (J\f. H.), that simple rest may restore ureteral tone and stop reflux, with no operative procedure at all on the ureterovesical juncture. There appeared to be no measurable difference between the 2 ureters in this case when first seen and we have no explanation of why rest failed to com-
Fm. 14. C. B. A, after 3 weeks of constant electrical stimulation there is still right ureteral reflux but none into kidney. B, 6 weeks later ureterorenal reflux present on right. C, 10 weeks later no demo11strable right renal reflux.
Fm. 15. C. B., ureteral peristaltic waves show normal pressures and frequency after discontinuing electrical stimulation.
Fm. 16. C. B. A and B, 1 week after removal of suprapubic tube and 2 weeks after stopping electrical stimulation no reflux noted. C and D, 4 weeks after removal of suprapubic tube and 5 weeks after stopping electrical stimulation no reflux noted.
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pletely restore the left ureteral tone. We may speculate that it will take a longer period of rest to do this. In the cases E. S. and C. B. ureteral pressures did not return with prolonged periods of rest. Pressures were restored by relatively brief periods-several months-of electrical stimulation. Both urinary tracts have now been restored to regular bladder voidings and its accompanying pressure relationships. vVe are well aware that what seems like a good result at present may not withstand the stress of the years to come. However, it should be pointed out that with technical improvements in our present crude stimulator one could be 1nade which could be buried and recharged from the outside, as is now possible with cardiac pacemakers. The case of J. P., while technically a failure, points out several interesting aspects of ureteral physiology. By increasing the voltage to 9 volts, which is the limit of our present device, consistent
with a workable battery life, it was possible to produce peristaltic waves which were regular in form and frequency. It was never possible to produce anything near the normal ureteral pressures of 18 to 20 mm. Hg. This child was much , older and had had reflux for years. This suggests that there may be a ureteral exhaustion point of no return, after which the ureteral muscle bundles are incapable of producing normal pressure levels. Many investigators have already applied this to our clinical thinking when we suggest "the last operation first," namely, urinary diversion on cases of severely dilated ureters. With cutaneous diversion and better forms of electronic stimulators it may be possible in the future to restore those patients in whom. the diagnosis is made early enough to a normal urinary system. 3720 ·washington Ave., St. Louis, M.issouri 63108 (W.F.M.)