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A Clinical Study of 480 Cases of Urinary Lithiasis1
A CLINICAL STUDY OF 480 CASES OF URINARY LITHIASIS 1 HARREL L. HARRINGTON
From the Department of Surgery, Division of Urology, University of California Medical School
This study is based upon all the cases of urinary lithiasis seen at the University of California Hospital from July, 1929 to July, 1939. Everyone will concede that a great number of factors and relationships might be developed from such a study. It is not my intention, however, to conduct an exhaustive study of the subject or to offer any original discoveries, but rather to add to the statistics and emphasize certain features and treatments of this disease. In the belief that diagnosis and treatment have improved in recent years, I divided this study into two 5-year periods to facilitate comparison and to:demonstrate such improvements if they exist. ti Incidence. There has been an increase in the percentage of cases of urinary lithiasis"admitted to this hospital during the past 10 years (table 1). During the first 5 years, there were 166 proved cases and, during the last 5 years, 314 additional proved cases. Age, sex, financial status. In the first 5-year period, the oldest patient was 83 and the youngest 7 years of age. The majority were in the fourth and fifth decades of life. The males predominated by about 1.6 to 1. Approximately the same number of patients were seen on clinic and private services. In the second period, the oldest patient was 86 and the youngest 2 years of age. Again the majority of these patients were in the fourth and fifth decades of life. The males predominated by about 2 to 1. The clinic patients outnumbered those on the private service by 8 per cent. Race. For the 10-year period, all races except the Negro were represented. Unfortunately, significant observations as to racial predisposition to urinary lithiasis could not be made since it was impossible to determine the racial origin of all patients admitted to the hospital. Nearly all patients in this series were permanent residents within an area with a 200 mile radius from San Francisco. Location. Study of the location of stones in these patients revealed no significant differences between the two 5-year periods. This information, including familial history, is arranged in table 2. 1
Read at the meeting of the Clinical Society of Genito-Urinary Surgeons, March 19, 1940.
507
508
HARREL L. HARRINGTON
Composition. Unfortunately, a sufficient number of urinary calculi were not analyzed to make information as to their composition of any value. Obstructive and infectious factors. Information regarding infection and obstruction of the urinary tract, correlated to the location of the stones, is presented in table 3. In at least 26 per cent of all cases no infection could be demonstrated. In many cases no report was available as to whether or not infection was present. The true percentage of sterile cases in this series is undoubtedly higher than 26 per cent indicating TABLE
Yli:All
TOTAL NUKllEJt 011 AD· MISSIONS TO HOSPITAL
1929-1934 1934-1939 1929-1934 1934-1939
1
TOT AL NUKllE1t 011 AD· MISSIONS ON Ull.OLOGY SEJtVICE
.608 .932 7.65 12 .2
27,292 33,762 2,177 2,580 TABLE
PE1tCENTAGE OF P ATIENTS WITH CALCULUS
2.-Location of stones 1929-193{
1934-1939
LOCATION
Kidney . . . . .... .... . . .. . Ureter .. .. . ... ..... . .. .. Bladder .. . .. . .... . . ..... Prostate . . .. .. . .. .. . . . . . Urethra . . .. . .. .... .. ....
Right
Left
Bilateral
Right
Left
Bilateral
36 27 28 6 1
38 35 1*
18 3
65 60 43
68t 62
27 5
11
3
1929-1934: Familial history: Present, 6; not stated, 44. 1934-1939: Familial history : Present, 8; not stated, 131. * Gravel. t Sand, 1.
that infection cannot be indicted as the etiological agent in the majority of cases of urinary lithiasis. Diagnosis and symptoms. Table 4 sets forth the details of the methods of diagnosis employed and the 3 predominant symptoms correlated to the location of the calculi. It may be noted that during the last period more cases were diagnosed by the use of the wax bulb. The intravenous urogram and the cystogram also were employed more frequently and the retrograde pyelogram relatively less frequently. Over the 10-year period the predominant symptoms in each group were nearly identical.
TABLE
3.----0bstructive, infective factors
OBSTRUCTION TO
LOCATION OF STONE
NO OB· STRUC TION 0
FOUND
E ::l"
.:::
"
...i
1l., ... "'
i
iil
.,.,
NO IN· l'ECTION
""'
Jj
ORGANISMS FOUND
FOUND
ll
j
July 1929-1934 Left kidney
31
Right kidney
36
Left ureter
1'1
Right ureter
B
21
2
16
18
1
13
3
21
3
25
3
5
2
7
Bacillus coli. ..................... Streptococcus viridans .. ............. Staphylococcus albus .. . . . . . . . . . . . . . Streptococcus alpha. .. . . .. . .. . . .. . . . Bacillus proteus ..................... Bacillus pyocyaneus. ................ Staphylococcus aureus ............... Bacillus paracoli .. ................. Rods .. ' . . .. ' ...................... Cocci. ............................. Tubercle bacilli . . ...... . . . . . .. . . . . .
13 4
3 3 2 2 1 1 8
5 1
Bacillus coli ........................ Jl1 Bacillus proteus ..................... 5 Staphylococcus albus ... . ······· ..... 3 Streptococcus viridans ............... 3 Atypical B. coli ..................... 3 Streptococcus alpha ................. 3 Rods .... .......................... 4 Cocci .............................. 1 Bacillus coli. ....................... Staphylococcus al bus. ............... Streptococcus viridans ............... Bacillus pyocyaneus. .............. , . Bacillus para.coli .................... Bacillus proteus ..................... Staphylococcus aureus . .... ' ........ Rods. ............................ Cocci ..............................
7 2 2 1 I 1 1 9 2
Bacillus coli ........................ Bacillus proteus ..................... Staphylococcus albus. . . ......... ' ... Streptococcus alpha. . . . . . . . . . . . Atypical Bacillus coli .. .............. Rods. ... . . .. . . . .... .. . .. . .... .. . . .
7 2
Bacillus coli .. ...................... Bacillus proteus ..................... Staphylococcus aureus . .............. Cocci .............................. Rods .... . ' ........................
4
2 1 1 1
---Bladder
Uretlua
13
16
2
1
- - - - --No report in 48 cases
509
1 1 1 6
510
HARREL L. HARRINGTON TABLE
3.-Continued
OBSTRUCTION TO
LOCATION OF STONE
NO OB· STRUCTION FOUND
s" a
~
..:i
E .,
a
i
i:a
.......
NO IN• FEC'IION FOUND
b
ORGANISMS FOUND
lil
!
July 1934--1939 Left kidney
56
Right kidney
43
Left ureter
43
30
2
11
17
Bacillus coli . ... ... . .......... . ..... 12 Bacillus proteus .... .. ............... 7 Hemolytic Escherichia coli . .......... 6 Staphylococcus albus ... ..... ..... ... 5 Non-hemolytic Escherichia coli . ...... 5 Streptococcus viridans ............... 4 Bacillus pyocyaneus .. .. . . . ........ .. 3 Bacillus coli aerogenes ..... .... ...... 3 Staphylococcus aureus . .............. 2 Streptococcus alpha ... . ... ......... 1 Hemolytic streptococcus .. . .. ........ 1 Bacillus paracoli ............. . ...... 1 Streptococcus hemolyticus beta . . ..... 1 Rods . . ... .......... . . .......... . . . 12 Cocci ............. ... .. ..... . ..... . 5
12
Bacillus coli . ........... ......... .. . 10 Staphylococcus albus . . .... .. . ... .. .. 9 Bacillus proteus . . ... .. . .... . .. ...... 7 Hemolytic Escherichia coli ... . . ...... 6 Streptococcus viridans .. . . . .......... 4 Bacillus coli aerogenes .......... . .... 3 Non-hemolytic Escherichia coli .... ... 3 Bacillus pyocyaneus . .. . .. .... .. .... . 2 Streptococcus alpha ............. .. . . 2 Staphylococcus aureus . ........ . . .... 1 Bacillus paracoli .. . ..... .... .. ... ... 1 Hemolytic staphylococcus albus .. ..... 1 Streptococcus hemolyticus Beta ... . .. . 1 Rods ... .. .. .. ...... . ...... . . .. .... 15 Cocci ... .. . .... . .... ....... .. . ..... 4
19
Staphylococcus albus . .... ... . ... .... Bacillus coli . ... ....... . ......... ... Bacillus proteus ............. ........ Streptococcus viridans . . . ... . .. ... ... Hemolytic Escherichia coli . .. . . .. . . . . Bacillus pyocyaneus ..... . .... ..... . . Streptococcus alpha ................. Staphylococcus aureus ........... , ... Rods .... .. . .. .. ........ . . .. .......
-----3
41
9
---- -20
1
5
7 4 3 3 3 1
1 1 1
1 CLINICAL STUDY OF URINARY LITHIASIS TABLE
511
3.-Conclude
OBSTllUCTION TO
LOCATION 01!' STONE
NOOB• STllUC· TION FOUND
i i ..:I
...
E
~
....~
NO IN• l'ECTION FOUND
OllGANlSl(S POUND
Iii
: ~
!
July 1934-1939- Continued Right ureter
41
Bladder
12
Urethra
1
1
23
1
16
Staphylococcus albus . . ... . . .. .. . .. . . 7 Bacillus coli .. . ... .. ... . . ... ... .. ... 5 Streptococcus viridans .. . . . . .. . .. . . .. 2 Bacillus coli aerogenes .... . . . . .... .. . 2 Hemolytic staphylococcus albus . ... . . . 1 Non-hemolytic Escherichia coli .. .. ... 1 Bacillus alcaligenes . .... ... . . .. . . . ... 1 Hemolytic Escherichia coli .. . . . .. . . .. 1 Rods . . .. . ... . ... .. .. . . ........ .. .. 3 Cocci .. ..... . .. . ..... . .. ... . .... .. . 3
1
Bacillus proteus ... ... .. ... . . .. . . . . . . 3 Bacillus coli ..... . . .. . . .... . . . . . .... 2 Staphylococcus albus .... .. . .... .. . .. 1 Rods ... . . .. ...... . . . . . .. . . . . . . .... 6 Cocci . . . . . . . . .. .......... . .. .. ..... 4
--- - -30
- -- -- 1
---
Rods . .. . .. ...... . ... ... .. . .... .. . .
1
No report in 118 cases
It may be of interest to mention the number of patients who passed or gave the history of passing calculi spontaneously and without instrumentation. For the first 5 years-27 before admission, 5 in the hospital, 5 after leaving the hospital. For the second 5 years-63 before admission, 5 in the hospital, 7 after leaving the hospital. Studies on the content of calcium and phosphorus in the blood were carried out on 49 patients. In only 1 case was hyperparathyroidism found. Treatment. (a) Diet and medication : It is evident (table 5) that there has been a great increase in the use of acid ash, high vitamin diets, and urinary antisepsis during the past 5 years. The antiseptics used include mandelic acid or one of its salts, sulfanilamide, and mandelamine given with acidifying salts. In the last 5 years most patients
512
HARREL L. HARRINGTON TABLE X·RAY, PLAIN,
LOCATION
WITH OR WITHOUT CATHETER
4.-Methods of diagnosis and predominant symptoms WAX
BULB
I.V. tJRO· GRAM
llETJI.O· GRADE
PYELO· GRAM:
SEEN AT CYSTO· SCOPY
CYSTO• GB.AK
SYMPTOMS
(a) 1929-1934 Kidney
94
0
Ureter
62
3
2
68
0
0
Pain .................. Hematuria .. . . . . ...... Pyuria ........... . ....
73 27 20
0
Pain . . .. .. .. . ... . .. ... Hematuria . . . ........ . Pyuria .. .. ..... .. .....
57
------ ---
Bladder
24
0
Prostate
5
0
Urethra
0
0
4
33
1
--------0 3 5
0
1
0
5
0
14 10
Hematuria ... . ...... .. Pain . ... ... . . ..... . . .. Frequency .. ... .... ...
10 10
Chronic prostatitis ..... Dysuria ... .. .. ... ... . . Frequency .. .. .. ... . ..
2 2 2
12
--------0
0
0
1
(b) 1934--1939 Kidney*
161
0
Uretert
115
9
--------42 54 8
1
Bladdert
27
0
--------4 5 13
11
Prostate
10
0
Urethra
2
0
33
106
Pain ...... .. .... . .... . 128 Hematuria ... ......... 49 Pyuria .. ....... .. . ... . 35
0
Pain .................. 114 Hematuria ..... . . .. .. . 31 Pyuria .. . . . . .. . ....... 8 Frequency .. .. ... ..... Dysuria ........... .. .. Hematuria . ...... ... . .
23 18 17
Chronic prostatitis .. . .. Dysuria ... ... ...... .. . Frequency .. . ... .. .. . .
4 2 2
--- --- --0
0
0
2
--- ------
0
0
0
1
* 1 found at postmortem; 1 felt at gall-bladder operation. t 2 found at postmortem. t 1 found at postmortem.
513
CLINICAL STUDY OF URINARY LITHIASIS
have been given high vitamin and acid ash diets (unless renal function was dangerously low), even though this is not stated in the hospital record, on the basis of which table 5 is composed. Over the same period the rate of recurrence has decreased. Perhaps some of the credit is due to increased and more persistent use of dietary regimes and urinary antisepsis. (b) Manipulation: The methods and results of manipulative treatment are shown in tables 6 and 7. Among the chief differences in manipulation in the last 5 years are the more frequent use of the basket, TABLE
5.-Treatment by diet and medication RECURRENCES
STATED URINARY ANTISEPTICS
STA'JI'ED DIET
recur~ All rencer,
I
Both
diet and med.
ID°only I cation Medionly iet
DIET NOT STATED
MEDICATION NOT STATED
1929-1934 14
Ketogenic Add ash Vitamin A
3
2 1
Acidifying
Ulcer diet
1
Ulcer regime 1
+
12
0
0
4
147
141
12
4
2
.3
245
243
3
1934-1939 Acid ash Vitamin A High vitamin Ketogenic Low oxalate Alkali ash Gallbladder Diabetic Nephritic
54 14 9 4
1 1 1 1 1
59
+ Acidifying + Antigen
34
1
instillation of avertin into the ureter, ureteral meatotomy, and improved visual instruments. (c) Surgical treatment: The general surgical procedures are presented tables 8 and 9, according to the location of the calculi. The total number of operations does not correspond to the number of patients operated on because a number of the patients had stones in more than one location which were removed by separate operations at different times. It is much more dangerous to incise the kidney or to leave a nephros-
514
HARREL L. HARRINGTON
tomy tube in place than it is to remove the stone by an incision in the pelvis only (table 10). The results fully bear out the foregoing contention. TABLE
LOCATION
~ 0 ~
<
<.>
6.-Manipulation of calculi in upper tract
.!S"' ..
+oi
reo
~i!:
. .~"'
oi
pP
<.>
"'
t; .. ~~
M.,
.:. z la 0
s., . .. ""' +~
z M,:,
;j,,.
· fil
u!il
.;
"' z
<.: :,i <
~~
z
;j
"'
oi
t.l
0
fjl
re
~ ·Z
p
<
{j
"~
8p
<.>
"'~ tl~
..
= = 0 0 0
~
p
<.>
1929-1934: 25 manipulated
L . ureter ... . . 18 R. ureter .... . 5 1 K idney .. ... .
1
7 2
10 3
1
9 3 1
5 2 1
1 1
9 3
9 16
2 7
12 10
17 8
1934-1939: 71 manipulated
I
L. ureter . .... 23 110 7 9 4 3 10 14 R. ureter . . .. . 25 6 4 4 7 4 Kidney ... . .. 1 postural manipulation-not successful
I I
I
I
1 0 (1.4%)
1 patient died after multiple manipulations. Postmortem revealed multiple left renal abscesses, B. coli septicemia, ruptured acute gall-bladder and liver abscesses. 1929-1934: No mortality. 1934-1939: 1 case-stone left ureter. TABLE
7.-Manipulation of calculi in lower tract
"Po.
LOCATION
~t
Z"'
0"
"
.,-;;;
!= ..c,
., " "'fil ~
.
"z 1-
,..o
.
"'~ ~< z
Oo Pl ..
1::~
.;
z!.
.,.;
z
~
. =~ .z .... .... ~~
oO
:,i
0
M ..
~
fjl
.,<
0
0
.,.; @ p "'
~
a B =
§
.
<
" 0
)II
1929-1934: 17 manipulated Bladder .... .. ... . .. ·
I
5
10
0
1934-1939: 26 manipulated Bladder .. . . .... . . . . · Urethra ......... . ...
I 121 I
2
1
1
1 case : daily bladder irrigations with acetic acid 1/500. * Forceps.
0
0
0
0
Calcareous material disappeared.
Results. During the first 5 years calculi were removed from 73 patients with 2 deaths; nephrectomy was required in 16 cases with 1 death. The total mortality rate for removal of calculi, regardless of method, in the upper urinary tract was 3.37 per cent. During the last 5 years
515
CLINICAL STUDY OF URINARY LITHIASIS
calculi were removed from 100 patients with 4 deaths, and nephrectomy was employed in 34 cases with 1 death. The total mortality rate was 3.65 per cent. TABLE
8.-Results of surgery of upper urinary /r(J(;t
,.,
~
r.l
5<
....
"'... LOCATION
~ ti
0
:;]
>
0
:ii
r.l
~
ztl
a.. a p
~
ti
0
:ii
...< >
0
"
= =
0
m r.l
.....z,.,
~~
a. . 00
~
,,i
r.l
t: <
re0
r.l~
~o
.;ti 0.r.l
..
0~
•Ill ~
r
p r.l
r.l
~14
za <., lllr.l E-<:,i
1:J;:J o~ )II
~
0
)II
~
TOTAL MORTALITY
0
ti,.,
1:J
5
Ill<
::; .... z
*1929-1934: No. of patients having surgery, 89 L. kidney ...... .. .... . 20 R. kidney ..... . . ... .. 24 Bilateral kidney .. ..... 1 L. ureter ......... .. .. 17 R. ureter .......... .. . 13 1 Bilateral ureter . ..... ..
2 3 0 0 0 0
6 4 0 3 2 0
0 0 1 1 0 0
5
6 8
1 0
4
1 1 0
0 0
1 2
0 0 1 0 0
0 0 1 (I) 2 (FH, LD) 0 0
0 1 0 0 0
2 1 1 1 0
t1934-1939: No. of patients having surgery, 134 L. kidney ............ . R . kidney ...... . ..... L. ureter ............. R. ureter . . . . .. ....... Bilateral ureter . . .... ..
40 39 12 23 2
0 2 0 0 0
4 4 1 0 0
2 0 1 1 0
13 16 3 2 0
0 0 0 0 0
2
5 1 0 0
(JR, FP) (OS) (FL) (HB)
*Nephropexy also done. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pyelo- and uretero-pelvic plastics also done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Permanent nephrostomy also done ..... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vesical diverticulectomy also done .............. . .. .. ... . .. ............ .... .... . . Nephrostomy only done.. ......... . ...... ... . ... ... .... .... .. .. .. . .. ... .... .... Drainage of perinephric abscess only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 4 1 1 1 1
tNephropexy with or without plastics also done ........... .. . .. ........ .. . . ........ Removal by unilateral partial nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Removal by bilateral heminephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Removal of calculi through nephrostomy wound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drainage of perinephric abscess only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stone removed from one side plus bilateral nephrostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . Stone removed from one side plus nephrectomy for congenital atrophic kidney on the other side. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9 3 1 3 2 1 1
Calculi were removed from the lower urinary tract of 15 patients during the first period and from 18 patients during the last period. No deaths occurred.
516
HARREL L. HARRINGTON
In every instance the rate of recurrence has been substantially reduced in the last 5 years (table 10). The increased use of x-ray at operation in cases of multiple lithiasis is undoubtedly a great factor in this reduction. The general rate of recurrence after removal of stones from the kidney by all methods was 18.6 per cent during the first period and 10.9 per cent for the second period. In each period 8 patients supplied all the separate recurrences given in table 10. The rate of recurrence for all patients with lithiasis regardless of treatment given was as follows: 1929- 1934, 8.82 per cent (12 patients) 1934- 1939, 4.95 per cent (12 patients)
Patients receiving no treatment were excluded. These rates are undoubtedly too high because, for the 10-year period, only 5 patients were TABLE
9.-Results of lower tract surgery
I
LOCATION
SUPllA· PUBIC
I
PElHNEAL
I
T ,U .K. .
llECUll· RENCES
I
KOllTALlTY
1929-1934: No. of patients with surgery, 15 Bladder.. . . . . . . .. .... .. . ... . . . .. . Prostate . .. .... .. .. .. . . . .. . .. . . .. . Urethra.. .. . . . .. . .. .. . . ... ... .. . .
11
1 2
0
2 0 0
1
0 0 0
1934-1939: No. of patients with surgery, 18 Bladder . .. . ... . .. .. ... . .. .. . .... . Prostate . . . .... . . . . . .. . .. . . . .. . .. . Urethra .. . .... . . .. . . . . .. . . .... . . .
6 0 0
5 6
1
1 0 0
0 0
0
0 0 0
proved by x-ray to be completely free of calculi after the removal of all calculi supposedly present. Analysis of Surgical Mortality. From 1929 to 1934 there were 5 deaths among 104 patients operated on, a mortality of 4.8 per cent. W. D ., a man 53 years old, on the private service, died in uremia 1 day after bilateral removal of calculi and nephrostomy. F. H ., a male clinic patient 74 years of age died of urinary sepsis and cardiac failure 8 days after removal of calculi from the left ureter, bladder, and urethra. L. D., a male clinic patient 48 years old, had a carbuncle of the left kidney. A staphylococcus septicemia developed and the patient died 15 days after left nephrectomy, removal of the calculus and the upper third of the left ureter with drainage of a perinephric abscess. G. A., a male clinic patient, 50 years old, had a right perinephric abscess with perforation of the diaphragm. Thoracentesis and drainage of the abscess only were done. Bilateral renal calculi were present.
tllUNARY
CLIN][CAL STUDY OF TABLE
:L!THIASIS
10.-Summary of pyelotomy, nephrotomy and nephrostomy factors
In.ml
OPERA.TXON
PATIEN'l'S
RECURRENCES
I I T!~~~
TAKEN x~AuAT OP.
I
PROVED NEG. BY X-RAY AT
OP.
July 1929-1934: 43 patients* Pyelotomy only ...................... Nephrotomy only .................... Both pyelotomy and nephrotomy ....... Nephrotomy with nephrostomy ........ Both pyelotomy and nephrotomy with nephrostomy. . . . . . . . . . . . . ' . . . . . . . . 1 case; right side-pyelotomy and nephrotomy nephrostomy resection lower pole 2 times (October and December, 1930); left side-pyelotomy and nephrotomy decapsulation ........
+
22 3 4
3
3
r8%
0 2
0
0
0 0
0 0
1
4
2
Left
Left only
0
0 0
2
27.7%
15
4
+
+
Bilat.
only
1 case: bilateral pyelotomy + nephrotomy + nephrostomy ..........
Yes
July 1934--1939: 73 patientst Pyelotomy only .. .................... Nephrotomy only .................... Both pyelotomy and nephrotomy ....... Nephrotomy with nephrostomy ........ Both pyelotomy and nephrotomy with nephrostomy . ' ............... ' .... Pyelotomy with pyelostomy ........... Pyelotomy and nephrotomy with pyelostomy ....... .................... Calculi removed by resection lower pole kidney ......... , .................. Calculi removed by resection upper pole kidney ............................ 2 cases: bilat. pyelotomy, nephrotomy, nephrostomy .... ................... 1 case: bilateral nephrotomy with nephrostomy ........... . . . . . ' . . . . . . . . 1 case: bilateral nephrotomy only .......
33 5 9
7
3
!l
14
3%
0
3
0
0
0
7
1
2
1
3 0
7 2
16% 0
6 0
3
1
2 0
1
0
0
0
0
1
0
0
1
1
1
0
0
0
0
1
0
1
1
0
1 0
0
0 0
18
0
0
0
* In one case the stone was in a horseshoe kidney. Number of patients having recurrence: 8 (18.6%). t In one case the stone was in a horseshoe kidney (J. B.). Number of patients having recurrence: 8 (10.9%),
G. M., a man 66 years of age, on the private service, died on the fifth day after exploration of the left ureter for calculus, biopsy, removal of the median lobe, and suprapubic cystostomy. No calculus was found. He had caseating
518
HARREL L. HARRINGTON
tuberculosis of the bladder, miliary tuberculosis, pneumonia, bilateral pyelonephritis and pyo-ureters. From 1934 to 1939 there were 6 deaths among 152 patients operated on, a mortality of 3.94 per cent.
J. R., a male patient 67 years old, died in uremia 4 days after left nephrostomy and removal of calculus. His right kidney was infantile. F. P., a woman 48 years of age, died of disseminated tuberculous pneumonia, peritonitis, and obstruction of the small bowel 11 days after operation. She had had bilateral removal of renal calculi, there being 8 weeks between the operations. 0. S., a man 36 years of age, on the private service, died of shock one day after nephrectomy. F. L., a woman 40 years of age, _o n the clinic service, had extensive embolism 2 weeks after the removal of a left ureteral calculus. She died 1 week later, 7 days after amputation of the left leg. Subacute bacterial endocarditis was the source of the embolism. TABLE
11
TIME FOLLOWED
No follow-up. . . . .. . ... . . . . .. . .... . ... .. ..... Up to 1 year..... . .. ...... . . . .. .. . . ... ... ... 1 to 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 to 10 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NUMBER OF CASES
105 72 191 88
PERCENTAGE OF TOTAL
23 .0 16.0 41. 7 19.3
H. B., a woman 23 years of age, on the clinic service, died 24 days after right ureterolithotomy. Anuria and peritonitis developed on the eighth day after operation. Autopsy showed B. coli septicemia, bronchopneumonia, toxic hepatitis, peritonitis, bilateral hydronephrosis, ureteritis, and pyelonephritis. G. T., a man 62 years of age, on '.the 'clinic service, died 1 week after drainage of perinephric abscess and empyema. The follow-up of patients is shown in table 11. SUMMARY AND CONCLUSIONS
A clinical study of 480 consecutive cases of urinary lithiasis is reported. No new evidence of etiology was obtained. Although considerable progress has been made in the successful treatment of this disease, there is yet room for improvement. Routine analysis of all calculi removed would add to our understanding of this disease.
CLINICAL STUDY OF URINARY LITHIASIS
519
The importance of using the wax bulb and the intravenous urogram in making the diagnosis is emphasized. The necessity for knowing the status of renal function, use of the appropriate diet and of urinary antisepsis if infection is present, is reiterated. The routine use of x-rays after operation, and at the time of operation in cases of multiple lithiasis is heartily endorsed. In expert hands, the non-surgical removal of ureteral calculi by manipulation is a safe and highly satisfactory procedure. The risk of incising the kidney is demonstrated again in this study.
From the Department of Surgery, Division of Urology, University of California Medical School
This study is based upon all the cases of urinary lithiasis seen at the University of California Hospital from July, 1929 to July, 1939. Everyone will concede that a great number of factors and relationships might be developed from such a study. It is not my intention, however, to conduct an exhaustive study of the subject or to offer any original discoveries, but rather to add to the statistics and emphasize certain features and treatments of this disease. In the belief that diagnosis and treatment have improved in recent years, I divided this study into two 5-year periods to facilitate comparison and to:demonstrate such improvements if they exist. ti Incidence. There has been an increase in the percentage of cases of urinary lithiasis"admitted to this hospital during the past 10 years (table 1). During the first 5 years, there were 166 proved cases and, during the last 5 years, 314 additional proved cases. Age, sex, financial status. In the first 5-year period, the oldest patient was 83 and the youngest 7 years of age. The majority were in the fourth and fifth decades of life. The males predominated by about 1.6 to 1. Approximately the same number of patients were seen on clinic and private services. In the second period, the oldest patient was 86 and the youngest 2 years of age. Again the majority of these patients were in the fourth and fifth decades of life. The males predominated by about 2 to 1. The clinic patients outnumbered those on the private service by 8 per cent. Race. For the 10-year period, all races except the Negro were represented. Unfortunately, significant observations as to racial predisposition to urinary lithiasis could not be made since it was impossible to determine the racial origin of all patients admitted to the hospital. Nearly all patients in this series were permanent residents within an area with a 200 mile radius from San Francisco. Location. Study of the location of stones in these patients revealed no significant differences between the two 5-year periods. This information, including familial history, is arranged in table 2. 1
Read at the meeting of the Clinical Society of Genito-Urinary Surgeons, March 19, 1940.
507
508
HARREL L. HARRINGTON
Composition. Unfortunately, a sufficient number of urinary calculi were not analyzed to make information as to their composition of any value. Obstructive and infectious factors. Information regarding infection and obstruction of the urinary tract, correlated to the location of the stones, is presented in table 3. In at least 26 per cent of all cases no infection could be demonstrated. In many cases no report was available as to whether or not infection was present. The true percentage of sterile cases in this series is undoubtedly higher than 26 per cent indicating TABLE
Yli:All
TOTAL NUKllEJt 011 AD· MISSIONS TO HOSPITAL
1929-1934 1934-1939 1929-1934 1934-1939
1
TOT AL NUKllE1t 011 AD· MISSIONS ON Ull.OLOGY SEJtVICE
.608 .932 7.65 12 .2
27,292 33,762 2,177 2,580 TABLE
PE1tCENTAGE OF P ATIENTS WITH CALCULUS
2.-Location of stones 1929-193{
1934-1939
LOCATION
Kidney . . . . .... .... . . .. . Ureter .. .. . ... ..... . .. .. Bladder .. . .. . .... . . ..... Prostate . . .. .. . .. .. . . . . . Urethra . . .. . .. .... .. ....
Right
Left
Bilateral
Right
Left
Bilateral
36 27 28 6 1
38 35 1*
18 3
65 60 43
68t 62
27 5
11
3
1929-1934: Familial history: Present, 6; not stated, 44. 1934-1939: Familial history : Present, 8; not stated, 131. * Gravel. t Sand, 1.
that infection cannot be indicted as the etiological agent in the majority of cases of urinary lithiasis. Diagnosis and symptoms. Table 4 sets forth the details of the methods of diagnosis employed and the 3 predominant symptoms correlated to the location of the calculi. It may be noted that during the last period more cases were diagnosed by the use of the wax bulb. The intravenous urogram and the cystogram also were employed more frequently and the retrograde pyelogram relatively less frequently. Over the 10-year period the predominant symptoms in each group were nearly identical.
TABLE
3.----0bstructive, infective factors
OBSTRUCTION TO
LOCATION OF STONE
NO OB· STRUC TION 0
FOUND
E ::l"
.:::
"
...i
1l., ... "'
i
iil
.,.,
NO IN· l'ECTION
""'
Jj
ORGANISMS FOUND
FOUND
ll
j
July 1929-1934 Left kidney
31
Right kidney
36
Left ureter
1'1
Right ureter
B
21
2
16
18
1
13
3
21
3
25
3
5
2
7
Bacillus coli. ..................... Streptococcus viridans .. ............. Staphylococcus albus .. . . . . . . . . . . . . . Streptococcus alpha. .. . . .. . .. . . .. . . . Bacillus proteus ..................... Bacillus pyocyaneus. ................ Staphylococcus aureus ............... Bacillus paracoli .. ................. Rods .. ' . . .. ' ...................... Cocci. ............................. Tubercle bacilli . . ...... . . . . . .. . . . . .
13 4
3 3 2 2 1 1 8
5 1
Bacillus coli ........................ Jl1 Bacillus proteus ..................... 5 Staphylococcus albus ... . ······· ..... 3 Streptococcus viridans ............... 3 Atypical B. coli ..................... 3 Streptococcus alpha ................. 3 Rods .... .......................... 4 Cocci .............................. 1 Bacillus coli. ....................... Staphylococcus al bus. ............... Streptococcus viridans ............... Bacillus pyocyaneus. .............. , . Bacillus para.coli .................... Bacillus proteus ..................... Staphylococcus aureus . .... ' ........ Rods. ............................ Cocci ..............................
7 2 2 1 I 1 1 9 2
Bacillus coli ........................ Bacillus proteus ..................... Staphylococcus albus. . . ......... ' ... Streptococcus alpha. . . . . . . . . . . . Atypical Bacillus coli .. .............. Rods. ... . . .. . . . .... .. . .. . .... .. . . .
7 2
Bacillus coli .. ...................... Bacillus proteus ..................... Staphylococcus aureus . .............. Cocci .............................. Rods .... . ' ........................
4
2 1 1 1
---Bladder
Uretlua
13
16
2
1
- - - - --No report in 48 cases
509
1 1 1 6
510
HARREL L. HARRINGTON TABLE
3.-Continued
OBSTRUCTION TO
LOCATION OF STONE
NO OB· STRUCTION FOUND
s" a
~
..:i
E .,
a
i
i:a
.......
NO IN• FEC'IION FOUND
b
ORGANISMS FOUND
lil
!
July 1934--1939 Left kidney
56
Right kidney
43
Left ureter
43
30
2
11
17
Bacillus coli . ... ... . .......... . ..... 12 Bacillus proteus .... .. ............... 7 Hemolytic Escherichia coli . .......... 6 Staphylococcus albus ... ..... ..... ... 5 Non-hemolytic Escherichia coli . ...... 5 Streptococcus viridans ............... 4 Bacillus pyocyaneus .. .. . . . ........ .. 3 Bacillus coli aerogenes ..... .... ...... 3 Staphylococcus aureus . .............. 2 Streptococcus alpha ... . ... ......... 1 Hemolytic streptococcus .. . .. ........ 1 Bacillus paracoli ............. . ...... 1 Streptococcus hemolyticus beta . . ..... 1 Rods . . ... .......... . . .......... . . . 12 Cocci ............. ... .. ..... . ..... . 5
12
Bacillus coli . ........... ......... .. . 10 Staphylococcus albus . . .... .. . ... .. .. 9 Bacillus proteus . . ... .. . .... . .. ...... 7 Hemolytic Escherichia coli ... . . ...... 6 Streptococcus viridans .. . . . .......... 4 Bacillus coli aerogenes .......... . .... 3 Non-hemolytic Escherichia coli .... ... 3 Bacillus pyocyaneus . .. . .. .... .. .... . 2 Streptococcus alpha ............. .. . . 2 Staphylococcus aureus . ........ . . .... 1 Bacillus paracoli .. . ..... .... .. ... ... 1 Hemolytic staphylococcus albus .. ..... 1 Streptococcus hemolyticus Beta ... . .. . 1 Rods ... .. .. .. ...... . ...... . . .. .... 15 Cocci ... .. . .... . .... ....... .. . ..... 4
19
Staphylococcus albus . .... ... . ... .... Bacillus coli . ... ....... . ......... ... Bacillus proteus ............. ........ Streptococcus viridans . . . ... . .. ... ... Hemolytic Escherichia coli . .. . . .. . . . . Bacillus pyocyaneus ..... . .... ..... . . Streptococcus alpha ................. Staphylococcus aureus ........... , ... Rods .... .. . .. .. ........ . . .. .......
-----3
41
9
---- -20
1
5
7 4 3 3 3 1
1 1 1
1 CLINICAL STUDY OF URINARY LITHIASIS TABLE
511
3.-Conclude
OBSTllUCTION TO
LOCATION 01!' STONE
NOOB• STllUC· TION FOUND
i i ..:I
...
E
~
....~
NO IN• l'ECTION FOUND
OllGANlSl(S POUND
Iii
: ~
!
July 1934-1939- Continued Right ureter
41
Bladder
12
Urethra
1
1
23
1
16
Staphylococcus albus . . ... . . .. .. . .. . . 7 Bacillus coli .. . ... .. ... . . ... ... .. ... 5 Streptococcus viridans .. . . . . .. . .. . . .. 2 Bacillus coli aerogenes .... . . . . .... .. . 2 Hemolytic staphylococcus albus . ... . . . 1 Non-hemolytic Escherichia coli .. .. ... 1 Bacillus alcaligenes . .... ... . . .. . . . ... 1 Hemolytic Escherichia coli .. . . . .. . . .. 1 Rods . . .. . ... . ... .. .. . . ........ .. .. 3 Cocci .. ..... . .. . ..... . .. ... . .... .. . 3
1
Bacillus proteus ... ... .. ... . . .. . . . . . . 3 Bacillus coli ..... . . .. . . .... . . . . . .... 2 Staphylococcus albus .... .. . .... .. . .. 1 Rods ... . . .. ...... . . . . . .. . . . . . . .... 6 Cocci . . . . . . . . .. .......... . .. .. ..... 4
--- - -30
- -- -- 1
---
Rods . .. . .. ...... . ... ... .. . .... .. . .
1
No report in 118 cases
It may be of interest to mention the number of patients who passed or gave the history of passing calculi spontaneously and without instrumentation. For the first 5 years-27 before admission, 5 in the hospital, 5 after leaving the hospital. For the second 5 years-63 before admission, 5 in the hospital, 7 after leaving the hospital. Studies on the content of calcium and phosphorus in the blood were carried out on 49 patients. In only 1 case was hyperparathyroidism found. Treatment. (a) Diet and medication : It is evident (table 5) that there has been a great increase in the use of acid ash, high vitamin diets, and urinary antisepsis during the past 5 years. The antiseptics used include mandelic acid or one of its salts, sulfanilamide, and mandelamine given with acidifying salts. In the last 5 years most patients
512
HARREL L. HARRINGTON TABLE X·RAY, PLAIN,
LOCATION
WITH OR WITHOUT CATHETER
4.-Methods of diagnosis and predominant symptoms WAX
BULB
I.V. tJRO· GRAM
llETJI.O· GRADE
PYELO· GRAM:
SEEN AT CYSTO· SCOPY
CYSTO• GB.AK
SYMPTOMS
(a) 1929-1934 Kidney
94
0
Ureter
62
3
2
68
0
0
Pain .................. Hematuria .. . . . . ...... Pyuria ........... . ....
73 27 20
0
Pain . . .. .. .. . ... . .. ... Hematuria . . . ........ . Pyuria .. .. ..... .. .....
57
------ ---
Bladder
24
0
Prostate
5
0
Urethra
0
0
4
33
1
--------0 3 5
0
1
0
5
0
14 10
Hematuria ... . ...... .. Pain . ... ... . . ..... . . .. Frequency .. ... .... ...
10 10
Chronic prostatitis ..... Dysuria ... .. .. ... ... . . Frequency .. .. .. ... . ..
2 2 2
12
--------0
0
0
1
(b) 1934--1939 Kidney*
161
0
Uretert
115
9
--------42 54 8
1
Bladdert
27
0
--------4 5 13
11
Prostate
10
0
Urethra
2
0
33
106
Pain ...... .. .... . .... . 128 Hematuria ... ......... 49 Pyuria .. ....... .. . ... . 35
0
Pain .................. 114 Hematuria ..... . . .. .. . 31 Pyuria .. . . . . .. . ....... 8 Frequency .. .. ... ..... Dysuria ........... .. .. Hematuria . ...... ... . .
23 18 17
Chronic prostatitis .. . .. Dysuria ... ... ...... .. . Frequency .. . ... .. .. . .
4 2 2
--- --- --0
0
0
2
--- ------
0
0
0
1
* 1 found at postmortem; 1 felt at gall-bladder operation. t 2 found at postmortem. t 1 found at postmortem.
513
CLINICAL STUDY OF URINARY LITHIASIS
have been given high vitamin and acid ash diets (unless renal function was dangerously low), even though this is not stated in the hospital record, on the basis of which table 5 is composed. Over the same period the rate of recurrence has decreased. Perhaps some of the credit is due to increased and more persistent use of dietary regimes and urinary antisepsis. (b) Manipulation: The methods and results of manipulative treatment are shown in tables 6 and 7. Among the chief differences in manipulation in the last 5 years are the more frequent use of the basket, TABLE
5.-Treatment by diet and medication RECURRENCES
STATED URINARY ANTISEPTICS
STA'JI'ED DIET
recur~ All rencer,
I
Both
diet and med.
ID°only I cation Medionly iet
DIET NOT STATED
MEDICATION NOT STATED
1929-1934 14
Ketogenic Add ash Vitamin A
3
2 1
Acidifying
Ulcer diet
1
Ulcer regime 1
+
12
0
0
4
147
141
12
4
2
.3
245
243
3
1934-1939 Acid ash Vitamin A High vitamin Ketogenic Low oxalate Alkali ash Gallbladder Diabetic Nephritic
54 14 9 4
1 1 1 1 1
59
+ Acidifying + Antigen
34
1
instillation of avertin into the ureter, ureteral meatotomy, and improved visual instruments. (c) Surgical treatment: The general surgical procedures are presented tables 8 and 9, according to the location of the calculi. The total number of operations does not correspond to the number of patients operated on because a number of the patients had stones in more than one location which were removed by separate operations at different times. It is much more dangerous to incise the kidney or to leave a nephros-
514
HARREL L. HARRINGTON
tomy tube in place than it is to remove the stone by an incision in the pelvis only (table 10). The results fully bear out the foregoing contention. TABLE
LOCATION
~ 0 ~
<
<.>
6.-Manipulation of calculi in upper tract
.!S"' ..
+oi
reo
~i!:
. .~"'
oi
pP
<.>
"'
t; .. ~~
M.,
.:. z la 0
s., . .. ""' +~
z M,:,
;j,,.
· fil
u!il
.;
"' z
<.: :,i <
~~
z
;j
"'
oi
t.l
0
fjl
re
~ ·Z
p
<
{j
"~
8p
<.>
"'~ tl~
..
= = 0 0 0
~
p
<.>
1929-1934: 25 manipulated
L . ureter ... . . 18 R. ureter .... . 5 1 K idney .. ... .
1
7 2
10 3
1
9 3 1
5 2 1
1 1
9 3
9 16
2 7
12 10
17 8
1934-1939: 71 manipulated
I
L. ureter . .... 23 110 7 9 4 3 10 14 R. ureter . . .. . 25 6 4 4 7 4 Kidney ... . .. 1 postural manipulation-not successful
I I
I
I
1 0 (1.4%)
1 patient died after multiple manipulations. Postmortem revealed multiple left renal abscesses, B. coli septicemia, ruptured acute gall-bladder and liver abscesses. 1929-1934: No mortality. 1934-1939: 1 case-stone left ureter. TABLE
7.-Manipulation of calculi in lower tract
"Po.
LOCATION
~t
Z"'
0"
"
.,-;;;
!= ..c,
., " "'fil ~
.
"z 1-
,..o
.
"'~ ~< z
Oo Pl ..
1::~
.;
z!.
.,.;
z
~
. =~ .z .... .... ~~
oO
:,i
0
M ..
~
fjl
.,<
0
0
.,.; @ p "'
~
a B =
§
.
<
" 0
)II
1929-1934: 17 manipulated Bladder .... .. ... . .. ·
I
5
10
0
1934-1939: 26 manipulated Bladder .. . . .... . . . . · Urethra ......... . ...
I 121 I
2
1
1
1 case : daily bladder irrigations with acetic acid 1/500. * Forceps.
0
0
0
0
Calcareous material disappeared.
Results. During the first 5 years calculi were removed from 73 patients with 2 deaths; nephrectomy was required in 16 cases with 1 death. The total mortality rate for removal of calculi, regardless of method, in the upper urinary tract was 3.37 per cent. During the last 5 years
515
CLINICAL STUDY OF URINARY LITHIASIS
calculi were removed from 100 patients with 4 deaths, and nephrectomy was employed in 34 cases with 1 death. The total mortality rate was 3.65 per cent. TABLE
8.-Results of surgery of upper urinary /r(J(;t
,.,
~
r.l
5<
....
"'... LOCATION
~ ti
0
:;]
>
0
:ii
r.l
~
ztl
a.. a p
~
ti
0
:ii
...< >
0
"
= =
0
m r.l
.....z,.,
~~
a. . 00
~
,,i
r.l
t: <
re0
r.l~
~o
.;ti 0.r.l
..
0~
•Ill ~
r
p r.l
r.l
~14
za <., lllr.l E-<:,i
1:J;:J o~ )II
~
0
)II
~
TOTAL MORTALITY
0
ti,.,
1:J
5
Ill<
::; .... z
*1929-1934: No. of patients having surgery, 89 L. kidney ...... .. .... . 20 R. kidney ..... . . ... .. 24 Bilateral kidney .. ..... 1 L. ureter ......... .. .. 17 R. ureter .......... .. . 13 1 Bilateral ureter . ..... ..
2 3 0 0 0 0
6 4 0 3 2 0
0 0 1 1 0 0
5
6 8
1 0
4
1 1 0
0 0
1 2
0 0 1 0 0
0 0 1 (I) 2 (FH, LD) 0 0
0 1 0 0 0
2 1 1 1 0
t1934-1939: No. of patients having surgery, 134 L. kidney ............ . R . kidney ...... . ..... L. ureter ............. R. ureter . . . . .. ....... Bilateral ureter . . .... ..
40 39 12 23 2
0 2 0 0 0
4 4 1 0 0
2 0 1 1 0
13 16 3 2 0
0 0 0 0 0
2
5 1 0 0
(JR, FP) (OS) (FL) (HB)
*Nephropexy also done. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pyelo- and uretero-pelvic plastics also done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Permanent nephrostomy also done ..... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vesical diverticulectomy also done .............. . .. .. ... . .. ............ .... .... . . Nephrostomy only done.. ......... . ...... ... . ... ... .... .... .. .. .. . .. ... .... .... Drainage of perinephric abscess only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 4 1 1 1 1
tNephropexy with or without plastics also done ........... .. . .. ........ .. . . ........ Removal by unilateral partial nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Removal by bilateral heminephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Removal of calculi through nephrostomy wound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drainage of perinephric abscess only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stone removed from one side plus bilateral nephrostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . Stone removed from one side plus nephrectomy for congenital atrophic kidney on the other side. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9 3 1 3 2 1 1
Calculi were removed from the lower urinary tract of 15 patients during the first period and from 18 patients during the last period. No deaths occurred.
516
HARREL L. HARRINGTON
In every instance the rate of recurrence has been substantially reduced in the last 5 years (table 10). The increased use of x-ray at operation in cases of multiple lithiasis is undoubtedly a great factor in this reduction. The general rate of recurrence after removal of stones from the kidney by all methods was 18.6 per cent during the first period and 10.9 per cent for the second period. In each period 8 patients supplied all the separate recurrences given in table 10. The rate of recurrence for all patients with lithiasis regardless of treatment given was as follows: 1929- 1934, 8.82 per cent (12 patients) 1934- 1939, 4.95 per cent (12 patients)
Patients receiving no treatment were excluded. These rates are undoubtedly too high because, for the 10-year period, only 5 patients were TABLE
9.-Results of lower tract surgery
I
LOCATION
SUPllA· PUBIC
I
PElHNEAL
I
T ,U .K. .
llECUll· RENCES
I
KOllTALlTY
1929-1934: No. of patients with surgery, 15 Bladder.. . . . . . . .. .... .. . ... . . . .. . Prostate . .. .... .. .. .. . . . .. . .. . . .. . Urethra.. .. . . . .. . .. .. . . ... ... .. . .
11
1 2
0
2 0 0
1
0 0 0
1934-1939: No. of patients with surgery, 18 Bladder . .. . ... . .. .. ... . .. .. . .... . Prostate . . . .... . . . . . .. . .. . . . .. . .. . Urethra .. . .... . . .. . . . . .. . . .... . . .
6 0 0
5 6
1
1 0 0
0 0
0
0 0 0
proved by x-ray to be completely free of calculi after the removal of all calculi supposedly present. Analysis of Surgical Mortality. From 1929 to 1934 there were 5 deaths among 104 patients operated on, a mortality of 4.8 per cent. W. D ., a man 53 years old, on the private service, died in uremia 1 day after bilateral removal of calculi and nephrostomy. F. H ., a male clinic patient 74 years of age died of urinary sepsis and cardiac failure 8 days after removal of calculi from the left ureter, bladder, and urethra. L. D., a male clinic patient 48 years old, had a carbuncle of the left kidney. A staphylococcus septicemia developed and the patient died 15 days after left nephrectomy, removal of the calculus and the upper third of the left ureter with drainage of a perinephric abscess. G. A., a male clinic patient, 50 years old, had a right perinephric abscess with perforation of the diaphragm. Thoracentesis and drainage of the abscess only were done. Bilateral renal calculi were present.
tllUNARY
CLIN][CAL STUDY OF TABLE
:L!THIASIS
10.-Summary of pyelotomy, nephrotomy and nephrostomy factors
In.ml
OPERA.TXON
PATIEN'l'S
RECURRENCES
I I T!~~~
TAKEN x~AuAT OP.
I
PROVED NEG. BY X-RAY AT
OP.
July 1929-1934: 43 patients* Pyelotomy only ...................... Nephrotomy only .................... Both pyelotomy and nephrotomy ....... Nephrotomy with nephrostomy ........ Both pyelotomy and nephrotomy with nephrostomy. . . . . . . . . . . . . ' . . . . . . . . 1 case; right side-pyelotomy and nephrotomy nephrostomy resection lower pole 2 times (October and December, 1930); left side-pyelotomy and nephrotomy decapsulation ........
+
22 3 4
3
3
r8%
0 2
0
0
0 0
0 0
1
4
2
Left
Left only
0
0 0
2
27.7%
15
4
+
+
Bilat.
only
1 case: bilateral pyelotomy + nephrotomy + nephrostomy ..........
Yes
July 1934--1939: 73 patientst Pyelotomy only .. .................... Nephrotomy only .................... Both pyelotomy and nephrotomy ....... Nephrotomy with nephrostomy ........ Both pyelotomy and nephrotomy with nephrostomy . ' ............... ' .... Pyelotomy with pyelostomy ........... Pyelotomy and nephrotomy with pyelostomy ....... .................... Calculi removed by resection lower pole kidney ......... , .................. Calculi removed by resection upper pole kidney ............................ 2 cases: bilat. pyelotomy, nephrotomy, nephrostomy .... ................... 1 case: bilateral nephrotomy with nephrostomy ........... . . . . . ' . . . . . . . . 1 case: bilateral nephrotomy only .......
33 5 9
7
3
!l
14
3%
0
3
0
0
0
7
1
2
1
3 0
7 2
16% 0
6 0
3
1
2 0
1
0
0
0
0
1
0
0
1
1
1
0
0
0
0
1
0
1
1
0
1 0
0
0 0
18
0
0
0
* In one case the stone was in a horseshoe kidney. Number of patients having recurrence: 8 (18.6%). t In one case the stone was in a horseshoe kidney (J. B.). Number of patients having recurrence: 8 (10.9%),
G. M., a man 66 years of age, on the private service, died on the fifth day after exploration of the left ureter for calculus, biopsy, removal of the median lobe, and suprapubic cystostomy. No calculus was found. He had caseating
518
HARREL L. HARRINGTON
tuberculosis of the bladder, miliary tuberculosis, pneumonia, bilateral pyelonephritis and pyo-ureters. From 1934 to 1939 there were 6 deaths among 152 patients operated on, a mortality of 3.94 per cent.
J. R., a male patient 67 years old, died in uremia 4 days after left nephrostomy and removal of calculus. His right kidney was infantile. F. P., a woman 48 years of age, died of disseminated tuberculous pneumonia, peritonitis, and obstruction of the small bowel 11 days after operation. She had had bilateral removal of renal calculi, there being 8 weeks between the operations. 0. S., a man 36 years of age, on the private service, died of shock one day after nephrectomy. F. L., a woman 40 years of age, _o n the clinic service, had extensive embolism 2 weeks after the removal of a left ureteral calculus. She died 1 week later, 7 days after amputation of the left leg. Subacute bacterial endocarditis was the source of the embolism. TABLE
11
TIME FOLLOWED
No follow-up. . . . .. . ... . . . . .. . .... . ... .. ..... Up to 1 year..... . .. ...... . . . .. .. . . ... ... ... 1 to 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 to 10 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NUMBER OF CASES
105 72 191 88
PERCENTAGE OF TOTAL
23 .0 16.0 41. 7 19.3
H. B., a woman 23 years of age, on the clinic service, died 24 days after right ureterolithotomy. Anuria and peritonitis developed on the eighth day after operation. Autopsy showed B. coli septicemia, bronchopneumonia, toxic hepatitis, peritonitis, bilateral hydronephrosis, ureteritis, and pyelonephritis. G. T., a man 62 years of age, on '.the 'clinic service, died 1 week after drainage of perinephric abscess and empyema. The follow-up of patients is shown in table 11. SUMMARY AND CONCLUSIONS
A clinical study of 480 consecutive cases of urinary lithiasis is reported. No new evidence of etiology was obtained. Although considerable progress has been made in the successful treatment of this disease, there is yet room for improvement. Routine analysis of all calculi removed would add to our understanding of this disease.
CLINICAL STUDY OF URINARY LITHIASIS
519
The importance of using the wax bulb and the intravenous urogram in making the diagnosis is emphasized. The necessity for knowing the status of renal function, use of the appropriate diet and of urinary antisepsis if infection is present, is reiterated. The routine use of x-rays after operation, and at the time of operation in cases of multiple lithiasis is heartily endorsed. In expert hands, the non-surgical removal of ureteral calculi by manipulation is a safe and highly satisfactory procedure. The risk of incising the kidney is demonstrated again in this study.