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A Clinical Study of Forty-Nine Cases of Urinary Calculi Requiring Surgery1
A CLINICAL STUDY OF FORTY-NINE CASES OF URINARY CALCULI REQUIRING SURGERY1 CHARLES H. DET. SHIVERS AND KENNETH P. HENDERSON From the Urological Department of the Atlantic City Hospital
It is our purpose to enumerate the clinical and chemical findings in 49 cases of urinary calculi, and attempt to correlate the findings with the suspected etiological factors. These cases are grouped under 4 headings: ( 1) renal; (2) ureteral; (3) vesical; and (4) urethral. The calculi from 42 of these patients were available and for their quantitative chemical analysis we are indebted to Mr. Herman Brown, chemist to the Research Institute of Cutaneous Medicine, Philadelphia. Etiology. The literature on this subject is so voluminous that we will mention but few of the many investigators. The evidence at hand points to 2 possible methods of urinary stone formation: (1) a metabolic disturbance associated with excessive excretion of urinary crystalloids and an imbalance of the protective colloids; (2) an infection with or without mechanical obstruction. The valuable work of Keyser on hyperexcretory and infectious calculosis and Higgins on avitaminosis as an etiological factor in the production of stone is well known to you all. Since the work published by Barney and Mintz on the relationship of hyperparathyroidism to urinary calculi we have examined the blood calcium and phosphorus in twelve of our group. In no instance did we find an increase in the blood calcium or a decrease in the phosphorus. Joly mentions geographical distribution as a possible etiological factor but is unable to explain the prevalence of stone in one part of a country and the absence in another. The question of the influence of lime salts in drinking water is by no means settled as stone is quite common in Holland where the drinking water is reasonably free from lime salts and is rare in Switzerland where the rocks are calcareous and the water very hard. We find that the drinking water in Atlantic City is a mixture of cedar swamp and artesian. The cedar swamp water contains only .6 part per million of calcium and the combination pond and artesian contains 2 parts per million. The average hotel well contains 9 parts per million of calcium. 1 Read before the annual meeting of the American Urological Association, Quebec, Canada. June 30, 1938.
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URINARY CALCULI REQUIRING SURGERY
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The soil in Atlantic and Cape May Counties contains only a very small percentage of lime. Many of the people residing outside of .At· lantic City live in small communities that depend on surface well water to supply their needs. It would appear from our study that the low percentage of lime in drinking water in this locality in no way affects the status of calculi. \Vhen one considers the amount of calcium taken in foods there is no reason to be alarmed about the percentage of lime which is contained in drinking water. In considering the part played by focal infections, 25 patients had infected teeth, 2 were suffering from advanced pyorrhea and 4 from en· larged infected tonsils. None gave a history of any chronic intestinal disorder, except constipation, or of any skin, bone or joint disease. Cultures were not obtained routinely, but in 2 cases with infected teeth the non-hemolytic streptococcus and staphylococcus were present. Case No. 3557, in which the Staphylococcus albus and streptococcus were recovered from the root of an infected tooth, the staphylococcus was cultured from the left kidney which contained a moderate size calculus (qualitative analysis, Atlantic City Hospital). Case No. 6307 in which the non-hemolytic streptococcus was cultured from the root of a tooth, the same organism was recovered from the right kidney. This patient had a calculus in the pelvic portion of the right ureter (fig. 11). The focal infections in the remaining cases did not correspond with the organisms cultured from the urine. Renal calculi. In this series there were 14 cases of which 7 were females and 7 males. The renal involvement was entirely unilateral. In the former group 6 involved the right kidney and l the left kidney. The age incidence in the female group averaged 40 years, the youngest being 26 and the oldest 60. In the male group the right kidney was involved in 5 cases and the left kidney in 2 cases. The average age was 47 years, the youngest was 26 years of age and the oldest 69. Stones were found in the renal pelvis in 7 cases, a branched calculus was present in 3 cases, one patient suffered from a calculus at the ureteropelvic junction and in 3 other cases the stones were found in the calices. Nine showed Colon bacillus infection, 6 of which were present in an acid urine, 2 in an alkaline urine and 1 in a neutral urine. Three cases showed staphylococcus associated with Colon bacillus of which 2 were in an alkaline urine and 1 in a strongly acid urine. In 1 case we cultured a non-hemolytic streptococcus associated with Colon bacilli in a weakly acid urine. It is difficult to determine in any given case whether
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the infection found at examination preceded or followed the calculus formation. Renal ptosis was a contributing factor to urinary stasis in 2 cases which could be demonstrated preoperatively. Three cases at operation showed a definite thickening of the pelvic wall close to the ureter which was probably due to irritation caused by the calculus and infection. In the remaining cases obstruction to the urinary outflow was caused by the calculus alone. All patients showed definite improvement in back pressure following the removal of the calculus. None of the pa-
FIG. 1. Papin's technique of nephrostomy
tients in this group had been operated on previously for stone. Nephrectomy was done in 1 case, nephrolithotomy was performed in 4 cases and pelviolithotomy with nephrostomy in 9 cases (after the technique of Papin) (fig. 1) where a hemostat is introduced through the pelvic incision and a Malecot catheter drawn into the pelvis through one of the lower calices. We have followed this technique in most all cases where infection was present and have been very much gratified with our results. In most cases the infection responds readily to this treatment. As a rule the tube is removed in ten days and the fistulous tract heals promptly.
URINARY CALCULI REQUIRING SURGERY
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Case 1 (calculus No. 6). A female, age 48, with a branch calculus in the right kidney (fig. 2) gave a history of pain for a period of 9 years, frequency of urination and burning. The urine showed many pus cells and was weakly acid in reaction. The organism recovered was Colon bacillus. A quantitative estimation of renal function showed 5 per cent dye output from the right kidney and 35 per cent from the left kidney. A diagnosis of calculus pyonephrosis was made and nephrectomy carried out. After removal, the kidney was incised along its external border from pole to pole and all visible calculi removed. X-ray of the specimen (fig. 3) showed numerous shadows representing small fragments of stone left in the kidney.
FIG. 2. Case 1.
Staghorn calculus in right kidney
This case demonstrates the difficulty one has in removing stone fragments when nephrotomy is done for such a calculus without the aid of fluoroscopy and roentgenographic examination at the time of operation. Case 2 (calculus No. 4). A female, age 31, in whom we did not do a nephrostomy in the presence of infection after removing a calculus from the uteropelvic junction (fig. 4) preoperatively showed a large hydronephrosis with a ptosed kidney (fig. 5). Following pelvioureterolithotomy and nephropexy pelvic drainage was established but proved unsatisfactory and the convalescence was stormy. This patient had complained of pain in the right renal region for the past 6 months. The urine was acid in reaction and culture yielded B. coli. The end result was satisfactory (fig. 6) although it required
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repeated ureteral catheter drainage and the internal administration of mandelic acid before the infection entirely cleared up.
Fm. 3. Case 1. A, X-ray of kidney after sectioning, showing numerous small calculi remaining; B, plain x-ray of gross specimen of right kidney after removal of large calculus.
FIG. 4
FIG. S
FIG. 4. Case 2.
Intravenous urogram (45 minutes). Calculus at ureteropelvic junction showing dilatation of right renal pelvis. FIG. 5. Case 2. Intravenous urogram (30 minutes) taken in upright position. Note marked ptosis of right kidney with hydronephrosis.
Cases 2 and 3. These were cases of massive calculous pyonephroses, where the kidneys were densely adherent to the surrounding structures, the calculus
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URINARY CALCULI REQUIRING SURGERY
was removed and nephrostomy drainage established. shown marked improvement.
Both patients have
FIG. 6. Case 2. Postoperative right pyelogram in upright position. size of pelvis and good position of kidney.
Note decrease in
FIG. 7 FIG.8 FIG. 7. Case 4. Plain film showing calculus in right renal pelvis FIG. 8. Case 4. Preoperative right pyelogram showing large hydronephrosis
Case 4 (calculus B). A male, age 51, gave a history of chronic backache with acute exacerbations involving the right renal area for a period of 10 years. Examination revealed a moderate size calculus in the right renal pelvis (fig. 7) with no dye function. Preoperatively this patient had a urine which was
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C. H. DET. SHIVERS AND K. P. HENDERSON
weakly acid in reaction, 3 to 4 white blood cells per high power field and 1 to 3 red blood cells. The smears of the sediment were negative for organisms. The blood chemistry was normal. Forty-eight hours after ureteral drainage was established by cathether renal function was active as shown by indigo carmine output. A definite hydronephrosis was visualized (fig. 8). Following pelviolithotomy and nephrostomy (fig. 9) postoperative pyelogram showed a decrease in the size of the pelvis with a normal renal function. Case 5 (calculus No. 2). A woman, age 43, underwent an extensive nephrolithotomy for a branched calculus (fig. 10) because of poor function and infection of the opposite kidney. A small fragment of stone was left in the lower pole (fig. 11). The postoperative pyelogram showed considerable deformity of the pelvis (fig. 12). The renal function was surprisingly good
FIG. 9. Case 4.
Postoperative right pyelogram showing decrease in size of renal pelvis
and with the aid of mandelic acid the infection was reduced to a minimum with a reduction in the size of the x-ray shadow. This patient was treated for urinary infection for a period of 6 years before routine cystoscopic and x-ray examinations were carried out to make a correct diagnosis. The infecting organism was Colon bacillus. Case 6 (calculus No. 5). A female, age 60 years, gave a history of right renal colic over a period of S years. A plain x-ray taken of the kidney 3 years before showed a shadow in the region of the right renal pelvis. At the time of our first examination (fig. 13) we found a stone blocking the outflow of urine from the right renal pelvis with an infected but normal functioning left kidney. The patient was in poor general condition with frequent chills, high temperature and a high leukocyte count. The urine was strongly acid in
URINARY CALCULI REQUIRING SURGERY
Frn.11 10. Case 5. Plain film with ureteral catheters in situ showing calculus occupying left renal pelvis and calices. FIG. 11. Case 5. Plain film, postoperative, showing very faint shadow in lower pole of left kidney. FIG.
FIG. 12. Case 5. renal pelvis.
Postoperative left pyelogram showing considerable deformity of
reaction, contained 17 50 mgms. of albumin, innumerable pus cells and 20 to 30 red blood cells per high power field. The blood urea nitrogen was 33 mgms. per cent and the creatinin 3.4 mgms. per cent. On entrance to the hospital
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C. H. DET. SHIVERS AND K. P. HENDERSON
she refused operation so we attempted to establish renal drainage by catheter. This was only temporarily successful as the catheter slipped and became obstructed. Consent was given for operation at a time when the patient was almost moribund. The kidney was exposed by lumbar incision; drainage was established by nephrostomy. After incising the kidney at least a pint of purulent urine escaped. The stone could not be palpated. On account of the desperate condition of the patient we were satisfied with drainage alone. She made an uneventful recovery but refused further operative intervention for removal of the calculus. An attempt was then made to dissolve the stone. The pH of the urine was reduced with ammonium chloride, mandelic acid was administered for the colon infection and the renal pelvis was lavaged with
FIG. 13. Case 6. Plain film. vertebra, right side.
½to
Catheter in right ureter, calculus at level of third lumbar
2 per cent solution of phosphoric acid (as recommended by Randall and Campbell) and for a time a continuous flow of phosphoric acid was given through a ureteral catheter. There was a definite decrease in the size of the calculus (fig. 14). Its outer layers almost entirely disappeared leaving princi:Qally the nucleus which failed to reduce further in size. The stone was later removed by the sense of touch (fig. 15) through the nephrostomy opening, using Randall stone forceps. Convalescence was satisfactory. Case 7 (calculus Group 1). A female, age 30, was the only patient we lost in this group. She presented multiple calculi occupying the calices of the right kidney with a third degree ptosis (fig. 16). Some of them were literally filled with these stones. The kidneys functioned normally as shown by individual phthalein tests. A pelviolithotomy was unsuccessful as most of the
URINARY CALCULI REQUIRING SURGERY
375
stones were closely packed and densely adherent to the lining of the calices, To facilitate their removal an extensive nephrotomy was necessary. Grossly the parenchyma was normal throughout. There was practically no blood
FIG. 14 FIG. 15 FrG. 14. Case 6. Plain film after removal of nephrostomy tube, and insertion of ureteral catheter. Calculus shows a decrease in its outer layers, leaving principally nucleus. FIG. 15. Case 6. Plain film after removal of calculus through nephrostomy opening. Right ureteral catheter in situ,
Fm. 16. Case 7. Plain film with ureteral catheters in situ, showing ptosed right kidney with many small calculi in calices.
lost during the operation and nephrostomy drainage established. The operation took about 35 minutes and the patient was in good condition when she left the table. Directly afterwards, however, the pulse became rapid and
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was uncontrollable. A temperature followed and the patient died within 48 hours. There was no postoperative hemorrhage at any time as shown by blood count and clinical observation. The drainage from the renal pelvis was clear. Autopsy was refused. We have not been able to give a satisfactory explanation for the cause of death in this case. Certainly an extensive nephrolithotomy with subsequent renal damage is not an operation of choice where the opposite kidney is normal. One might question the surgical removal of some of these calculi because of their size. No cases presenting small renal stones were subjected to operation without first giving them an opportunity to pass the calculus following ureteral dilatation. In every case definite evidence of urostasis with infection was present. Cases we did not operate on immediately following their first cystoscopic and x-ray examination were kept under close observation and when evidence of back pressure increased we advised immediate surgical intervention. There has been no recurrence in this group. Ureteral calculi. There were 7 cases in this group, 2 men and 5 women. In the male group, 1 calculus was removed from the right lumbar ureter and the other from the intramural portion of the left ureter. In the female group the calculi were found and removed from the pelvic portion of the left ureter. Infection, due to B. coli, was pres-· ent in all but one in which the non-hemolytic streptococcus was cultured. Four cases showed urine weakly acid in reaction and 3 cases were strongly acid. The average age in the male was 44 years, the youngest being 32 and the oldest 57. In the female group the average age was 36 years, the youngest being 20 and the oldest 56. All of these patients recovered promptly from operation and none to date have had any recurrence. The interval in 2 cases has been 4 years, in 2 cases 1 year, in 1 case 4 months, and in 2 cases 3 months. Case 8 (calculus No. 12). A woman, age 56 was admitted to the Medical Service of the Atlantic City Hospital because of chills and fever. Her previous history was negative except for an attack of pain in the region of the left kidney about 6 months previous to admission with a slight recurrence shortly before admission. During her stay in the hospital she complained of no pain at any time. She was an obese individual and nothing was detected on physical examination. Because of the persistent pyuria we were requested to see the patient. We advised an intravenous urogram which shows (fig. 17)
URINARY CALCULI REQUIRING SURGERY
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FIG. 17. Case 8. Intravenous urogram, 5 minutes, preoperative. No excretion from left CalclJlus in lower left ureter. Shadow of left kidney shows a definite increase in size.
FIG. 18. Case 8. in left ureter.
Right pyelogram showing normal pelvis.
Calculus at tip of catheter
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prompt visualization of the right renal pelvis, and a triangular shaped shadow in the pelvic portion of the left ureter. No excretion of dye was detected from the affected side and the shadow of the left kidney showed a definite increase in size. The patient was transferred to the Urological Service. At cystoscopy the first attempt to pass the obstruction, which was 5 cm. from the ureteral orifice, was unsuccessful (fig. 18). Indigo carmine output from the right kidney was prompt with none from the left. No drainage was established through the left catheter. On a second attempt the obstruction was passed
FIG. 19 FIG. 20 FIG. 19. Case 8. Left pyelogram, preoperative, showing hydronephrosis. Calculus in left ureter at level of posterior inferior spine of ilium. FIG. 20. Case 8. Postoperative left pyelogram showing decrease in size of renal pelvis.
and the catheter introduced to the renal pelvis. 80 cc of purulent urine were removed. The pyelogram showed a large hydronephrosis (fig. 19), the catheter was left in situ for several days, the function of the kidney showed marked improvement, dilatation of the ureter was repeated and the patient given a fair chance to pass the calculus. On account of the damage already done to the left kidney we felt that time was an important factor and removed the stone surgically. Normal function has been established (fig. 20) with a decrease in the size of the renal pelvis.
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Retention of urine in the renal pelvis most commonly occurs in association with stones that have a part reaching into the ureter or from stones that are in the ureter itself. The case cited illustrates the damage which may occur from a so-called silent ureteral calculus. In none of these cases did we detect any obstruction in the ureter below the calculus. A few of the stones showed sharp projections protruding from the body which were embedded in the mucosa of the ureter and accounted for the fact that they remained largely stationary after repeated ureteral dilatation. We do not subscribe to the school advocating metal cystoscopic ureteral instruments for the removal of ureteral calculi, (1) because of the suffering the patient may have to undergo before the calculus finally
FIG. 2L Plain film showing vesical calculi in presence of prostatic enlargement
passes and (2) because of the injuries to the ureteral wall which occasionally occur. After operation, patients with renal or ureteral calculi are requested to report at stated intervals for proper follow-up treatment. If there is no evidence, after a time, of infection or obstruction the examination may consist only of a urinalysis. In all patients with focal infections such as teeth and tonsils an attempt was made to correct their infection either before or within a short period following operation. Vesical calculi. In this group we had 26 cases. All of the calculi were found in the presence of infection and, with 2 exceptions, behind mechanical obstruction. In all patients, culture 0£ the urine yielded
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B. coli. Ten calculi were found in the presence of alkaline urine, 9 in acid urine; 5 were found in neutral urine and 2 in weakly acid urine. We may further subdivide this group into those cases in which vesical calculi were found in the presence, (1) of adenomatous hypertrophy, (fig. 21) (2) contracture of the vesical neck; (3) urethral strictures, and (4) transvesical drainage. Case 9 (calculus No. 15). A moderate size calculus was found in the bladder of a colored woman, aged 55 (fig. 22). The urethra was literally filled with filiform strictures. Culture of the urine, which was slightly alkaline, yielded
Fm. 22. Case 9. Plain film showing calculus in bladder in presence of multiple filiform strictures of urethra.
B. coli. Following transvesical removal of the calculus and urethral dilatation, the patient made a complete recovery.
We feel that a certain number of these calculi were formed in the kidney. However, only 1 patient gave a history of left renal colic 6 months prior to admission at which time a small irregular dark calculus (No. 22) was found. Certainly stones may slip down from the kidney without producing any marked symptoms and if obstruction is present at the vesical neck or within the urethra they may attain considerable size.
In l case a calculus was reported in its formative stage attached to an unabsorbed suture in the anterior vesical wall. There was no obstruction at the vesical outlet or in the urethra.
URINARY CALCULI REQUIRING SURGERY
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Case 10. A hoy 9 years of age who was admitted to the hospital for correction of a hypospadias, developed a stone (No. 36) in the bladder during the time he was wearing a suprapubic drainage tube for the purpose of diverting the stream. At the time suprapubic drainage was established there was no urinary infection and the bladder was entirely negative for stone. Because of the abundance of phosphates in the urine it was necessary to change his tube weekly. His bladder was irrigated twice daily. He wore the tube for several months. A stone was suspected which was proven by x-ray shortly before the tube was permanently removed. Cultures of the urine showed the R coli. The urinary infection promptly cleared up after the removal of the stone and tube.
In none of the patients presenting calculi with obstruction where the obstruction was properly removed did the calculus recur even though
3S 9
2
3
FIG. 23. Case 11.
4
5
6
Urethral calculi
the infection was not entirely cleared up. We had 2 patients in which stones reformed. In both instances some obstruction remained Rt the vesical outlet. There was 1 death in this group from advanced renal infection due to B. coli. Urethral calculi were found in 2 cases, 1 male and 1 female. Case 11, (calculus No. 35) (fig. 23). A colored male, age 39, suffered for years from urethral strictures. A fistulous tract opening in the perineum was present. Calculi were shown by x-ray and could be detected by palpation. The stones were found in the bulbous portion of the urethra which was markedly dilated. The infection was severe.. The urine was neutral in reaction and cultures yielded B. coli. Case 11 (calculus G). A colored female, age 41, in whom a stone was found
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in a diverticulum of the urethra, was previously reported by Shivers and Cooney. We felt that the calculus formed in a pre-existing diverticulum as the patient gave no history of urinary symptoms and the urine which was alkaline was free of infection. There has been no recurrence of urethral stones following dilatation or surgery. Quantitative chemical analysis of the calculi. Quantitative determinations were made on the dried powdered samples for calcium, magnesium, ammonium, phosphorus, uric acid, oxalic acid and carbonic acid. These tests were made by adaption of micromethods used in blood chemistry (as little as SO mgm. of sample may be used). Qualitative tests were
FIG. 24. Renal calculi
also made of the less frequently occurring constituents such as cystine, fibrin, xanthin and creatinin. The results of the latter tests, as shown in the charts, indicate that they are only exceptionally found as impurities. The sample taken for analysis as nucleus consisted of that center portion of cut stone in which on gross examination no further evidence of subdivision could be observed. In more than one-third of the stones the nuclei were poorly defined. In nearly half the stones the gross physical appearance of the two areas was quite di:ff erent. Many stones exhibited nuclei of powdered or granular texture with hard, dense shells; in others the reverse condi-
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URINARY CALCULI REQUIRING SURGERY
1.-Chemical composition of renal calculi
TABLE
---P~ER_c_E_N·_r_oF_D_R_Y_w_Er_G-RT_ _ _
NO.
WT.
SAMPLE OF
.§ I ·2§
MOIS-
TURE
if)
a)
'-'"d
0
~-§
;;;
- - -------1--- --- per gm. cent
-
-
~ -<
--- -
-
- - ~ · - - - - - - -----
A
7 .O
f l
Shell Nucleus
1. 3 5. 0 0. 0 1 . 01' 0 . 7 0 .0 0 .0 0 . 8
B
f 24 l
Shell Nucleus
14.7143.7 0.0 0.0 2.741.0 0.0 0.0
C
3.5 {
Shell Nucleus
2.040.7 0.2 0.0 32.0 0.01 7.6 0.0 17 . 4 35 . 31 1 . 2 0. 0 30 . 7 0. 0 5 . 9 0 . 0
Shell Nucleus
5.940.410.8 0.0 31.1 0.0 4.3 3.3 4.3 40 .4i 1.2 0.0 33. 9 0.0 4.3 3 .5
( Shell 6.5 \ l Nucleus
4.0 44.81_ 0.0 o.o 31.1 o.o 8.6 2.2 4. 3 45 . 8 0 . 0 0 . 0 29 . 5 0 . 0 4 . 3 3 .4
I
fl
5 .0
3
0. 0 28. 8 38. 0 2. 8 0 . 0 28 . 8 33 . 0 2 . 2
I
2 ·5 \ 2
I
Shell Nucleus
0.0 0.055.8 0.0 2.61 0.054.3 0.0
I
I
1
1
43.2 ' 0.0[I 2.9!I 6.2 30.0 0.0 0.0 0.0 44.9 2.313.216.8 32.0 0.0 0.0 0.0
+ +
+ +
'·
2sf
4
0
Shell ( Nucleus
2.1 39.2I 1.5j 2.01 12.8 o.olzo) o.o
5
0 .45j Shell l Nucleus
3 :136.3' 0.01 0 0 16.01 0.0[2~.010.0 1 141.41 o o! o.o 14.2! 0.0 2.).9! o.o
1
1
2.8,35.81' 0 9\ 2.4\ 15.1 0.019.0, 0.0
I
i
I
i
I
I
I
1
6
f l
15
D
0 3
E
O
Shell Nucleus
i
1
Shell
i_\ Nucleus
.
6.239.2[ 2 8\ 0.8 30.4\ 0.01 O.OI 1.8 14.134.81 3.21 0.6, 30.91 0.0! o.o, 1.4 41.5 1 2.21 1.9) 3.9i 33 5\ o 0 0.0 1· 2.2 40.5 3.4. 1.8\ 3.6[ 30.t 4.8 0.0 3.4
I
1
17JI
I · \[ I F
i 1
'
Shell Nucleus
O 08 -
•
f]
l
Shell Nucleus
I
\
!
I
42.81 2.2i 2 01 4.oi 36.li 0.0 3.010.0 43.4! 4.5( 4.01 30.7 1 3.7 6.2 0.0
1.7;
i
!
I
:
'
I
.
40.0I 2.0 1 1.6) 1.9! 34.41 o.ol 3.01 1.8 41.1 3.8 1 1.5\ l.7! 3.2! 4.0 4.2\ 1.4 1
--
-
--
-
--
- I ---- [ --
I
1
! -
-
-
I -
I
--
-
!
\
I -
I -
i -
-
1
-
i [ I I
-
i --
--'-'- - - - - - - ' - - - - -
tion existed. In some of the calculi no apparent differences could be noted in the cut area. Renal calculi (fig. 24, table 1). The largest stone m this group weighed 22 gm. and the smallest .25 gm. In observing the following
384
C. H.
DET.
SHIVERS AND K. P. HENDERSON
tables one will see that despite physical dissimilarity, the chemical constitution of both the shell and nucleus of each calculus in the renal and ureteral groups are relatively similar. This chemical similarity despite physical dissimilarity is evident even in the minor constituents of these stones so that it would appear that the mechanism responsible for the initial formation of the nucleus continues unchanged throughout the life of the stone. In those calculi formed in sterile urine infection prob2.-Chemical composition of ureteral calculi
TABLE
PER CENT OF DRY WEIGHT
I
NO.
SAMPLE OF
WT.
I I MOIS-: i' s I TURE I s " I -~ " '
l
~
0
§~ O ~
-_,_,
~o.
J 1~
-§] ~]
8
s:::i
0
'"d
-~~
- -- - - - - -;;; -- - --i-- -1- -- - - - 1 gm.
7 1. 4
I
cent
f l
Shell Nucleus
I
I
I
I
9.5 36 9 0.3 0 0 20.6 0.01 7.9/ 4.3/ 6.336.9 0.2 0.017 20.017.912.81 1
1
1
I 12.137.01
I
I
I
8 0 _19{
Shell Nucleus
2.2 3.6 135.812.8 5 8. 5.6 1 14.433.0, 2.6 3.235.03.1 5.0' 4.8
9 0.2 {
Shell Nucleus
2.735.8/ o.o o.o 0.0,0.0 41.7 o.o 1.937.ol o.o o.o o.°j°.0(5.2 o.o
Shell Nucleus Entire stone Shell Nucleus
1.7 31.2, 0.010.018.44.9121.6 0.0 2.230.210.0, 0.0~20.8~6.1/11.1 0.0 4.0 43.6 0.8 o.0;32.0.0.01 8.6 o.o 1 2.0,35.8 1.11 0.01 0.0,0.0140.3 0.0 2.oi37.o 1.3 0.01o.oro143.210.0
I
I
1
1
10 0. 6 { 11 0.05
12 0.24{
13 0. 2 {
Shell Nucleus
1
+ +
1
14.4/28.0 0.7 0 0122.2,0.710.010.0, 17.5j26.8 0.8 0.0;23.2i°-9 0.01 0.01
ably occurred shortly before the patients were examined by us which would account for the absence of change in the shell of the stones. Only 1 stone was found to be relatively pure. Both the shell and nucleus of stone B consists of practically pure calcium oxalate with but a very small proportion of phosphate present in the nucleus that is not evident in the shell. All the other calculi in this group contained large amounts of calcium in both shell and nucleus combined with phosphate and oxalate with the exception of stone A and No. 3 which contain a small percentage of calcium in both the nucleus and shell. Stone A is a mixture of fixed alkali urate and oxalate and the close chemical
URINARY CALCULI REQUIRING SURGERY
385
similarity of its shell and nucleus is to be noted. Stone No. 3 is a mixture of magnesium, ammonium and fixed alkali phosphate. The low values for carbonate seen in this chart are evident in the other charts of this series. It appears that carbonate plays but a minor role in stone formation. It is noteworthy that stone A alone of the entire series shows uric acid as a major constituent while all the other calculi, with the exception of D, E and F are free of uric acid. Ureteral calculi (fig. 25, table 2). The largest ureteral stone removed weighed 1.4 gm. and the smallest .05 gm. Stone No. 9 is practically pure calcimn oxalate in both shell and nucleus. Stone No. 12 is a calcium oxalate stone mixed with about 2 per cent magnesium oxalate.
7
I()
II
I 3
FIG. 25. Ureteral calculi
It is interesting to note that the only single-constituent stones found in this series were composed of calcium oxalate. All tbe other stones are essentially mixtures of calcium phosphate and oxalate with the exception of No. 8 which also contains considerable ammonium phosphate. Vesical calculi (fig. 26, table 3). The largest stone in this group weighed 83.5 gm. and the smallest .3 gm. A portion of the vesical stones, unlike the renal and ureteral, show a definite difference between the shell and the nucleus. Only in those cases in which the entire stone formation occurred subsequent to infection are the analyses of both shell and nucleus substantially the same (Nos. 14, 15, 20, 21, 25, 26, 28, 29, 30, 31, and 36). These stones probably formed in alkaline,
TABLE
3.-Chemical composition of vesical calculi PER CENT OF DRY WEIGHT I
~o.
SAUPLE OF
WT.
E
MOIS-
TURE
s"' -3~ ~ '";;
----
-----
u
~-
~
-~
~~ on·~ ..,,o
"'~
""
---
s ·a"0 s s <
w"
e~ ~
0
.,:o
o.~
w
~
0"
-" 0.
p.,
~
] -~"' ;:5
--- --
~:-s"
2
0
"' cl
CYSTFIBRIN INE
XANTHIN
CRE.., ATININE
K
..0 0
~~
K
u
0
~-
-
~- ~- ~-
----
per cent
gm.
14
( Shell 22. 9132. 3 1.5 0.0 27.3 0.0 2.5 3.2 34.0 \ Nucleus I 27.527.6 1.1 3.5 27.3 0.5 1.8 4.3
15
Shell 16.0 { Nucleus \
-
-
-
-
-
-
-
-
-
!
Shell l Nucleus
1.8 0.0 0.0 4.5 8.1 0.0 0.0 0.0
0.0 60.0 0.0 0.0 0.0 56.8 0.0 0.0
-
-
-
-
(
1.0 0.0 0.0 0.0 0.9 0.0 0.0 0.0
0.0 64.8 0.0 0.0 0.0,64.8 0.0 0.0
-
-
-
-
Shell Nucleus
22.3 28.0 1.4 1.3 32.8 1. 7 2.9 1.5 2.1 37.0 0.0 0.0 6.6 0.8 37.4 0.0
-
-
-
-
-
Shell Nucleus
20.5 11.2 1.3 6.0 30.3 31.2 11.0 0.8 5.9 33.6 0.3 0.5 4.6 0.0 43.2 0.0
-
-
-
-
-
Shell
-
-
-
-
-
-
-
-
-
+ +
16
1.6 [
17
29.0 (
18
72.5 {
Shell
\ Nucleus
\ (
19
6.8
13.1 37.1 1.1 1.1 32.3 0.8 2.9 4.6 13 .4 35.8 1.4 0.8 27.3 0.8 2.2 4.5
j \
-
20
83.5 { Nucleus
18.8 28.0 2.1 1.5 32.4 0.0 1.4 2.5 13.9 35.8 0.7 0.4 34.1 0.0 1.4 2.2
-
21
Shell 15_0 { Nucleus
31.4 11.2 3.0 3.1 31.2 0.0 o.o] o.5 23.6 22.4 2 .4 1.4 24.4 0.014.410.5
-
(
22
0.4
t
Shell Nucleus
23
15 .6
l(
24
-
-
-
-
-
-
2 .4 28.0 0.7 1.8 23.7 0.0 4.3 2.4 4.9 37.0 0.5 0.9 12.7 0.0 28.8 2.0
-
-
-
-
24.6 4. 7 0.0 4.9 30. 7 0.0 1.6 0.0 38.2 11.8 1. 7 5.2 29.4 1. 2 2.1 0.0
-
-
-
-
Shell
41.3 4. 7 0.0 5.3 29.4 2.5 3.1 0.0 17.2 8.2 0.0 11. 7 12.3 6.8 1.6 0.4
-
-
+ +
-
Shell Nucleus
18.8 35.9 0.0 0.0 31.6 0.0 1.6 2.3 38.2 25.9 1.2 3.9 29.5 2.5 1.2 2.0
-
-
-
--
2.6 17.9 1.4 7.6 21. 7 24.4 27.4 1.4 2.7 11.8 1.6 9 .1 7.8 27.8 21.6 1.9
-
-
-
-
-
Shell Nucleus
l0.8 33.6 1.2 0.0 25.7 0.0 2.2 3.9 6.3 31.4 0.8 0.0 7.8 0.0 36.0 3.5
( Shell l Nucleus
0.4 \
I
Shell
46.0 )_ Nucleus
26
30.0 { Nucleus
27
52.0
t (
I
-
6.8 0.0140.3 0.0 7.5 0.0 41.8 0.0
25
28
1
-
Shell
0.5 { Nucleus
1.6 33.6 0.8 0.0 1.1 35.8 0.5 0.0
386
-
-
387
URINARY CALCULI REQUIRING SURGERY TABLE
----~ ~-
3.-Concluded
--
NO.
WT.
SAMPLE OF
Is
MOISTURF.
s"'
.2
~ a;,
]] cl 0
u
SJ]
"'0
:::: -
~
.2
I
..c,o
8
m~
0
a
-<
---
per
gm,
m"
2~ 0 k
~
a.~
0"
"O
·g u
.,.,..c, 0.
i§
---
--
I I
I
PER CENT OF DRY WEIGB:T ---~--~-
-;,"
"' k
0
§]" ~:.a u --
CYST- F BRI INE
•l
) XAN-
N' THIN
CRE-
ATIWINE
I
.0 0
I
-1--
cent
lf
Shell Nucleus
26.2 20.2 1 .1 3.1 23.0 5.0 3.4 0.0 33.8 24.6 l.3 2.1 18.9 0.0 8.9 0.0
r
Shell
14.9 34.7 1.8 2.1 30.1 2.3 4.3 3.0 18.4 28.0 1.5 2.1 28.5 3 6 4.3 2.5
0.8 \ Nucleus
( Shell
20.4 28.0 1.8 0.8124.5 1.51 5 .8 4.9 8.5 31.4 0.4 0.0 22.3 1.2 2.8 4.6
fl i Nucleus Shell
3.3 37.0 0.0 0.0 21.0 0.0 14.4 0.0 2.7 37 .0 0.0 0.0 5.2 1.8 30.3 0.0
29
3.2
30
1.0l Nucleus
31
32
O. S
33
1.2{
Shell Nucleus
0.8 0.0 0.0 0.0 2.3 3S.8 0.0 0.0
0.0 64.610.0 0.0 0.01 4.4145.2 0.0
34
0. 7
lf
Shell Nucleus
1.0 4.5 0.0 0.0 1.0 0.0 0.0 0.0
3.0152.0j 0.01 0.0 0.0:56.2i 0.0 0.0
36
2.
f l
Shell Nucleus
1.51
33.9 16.7 2 32.4 20.3 1.01 2.
36.8,i 0.01i 0.0 3.3 32.ol o.o o.o 2 6
+
--
-~------
infected urine. The analyses indicate progressive alkalinity with increased amounts of ammonium salts in the shell. Calculus Nos. 16, 18, 19, 22, 23, 24, 32, and 34 probably began formation in uninfected, acid urine and, as a result of the stone formation, the urine became infected with resulting deposits of phosphates followed by ammonium salts as the urine became more alkaline. The nuclei of these stones are calcium oxalate with two exceptions (16 and 34) which have uric acid nuclei. To be noted is one pure uric acid stone, No. 17, and one, No. 33, in which the nucleus is pure calcium oxalate and the shell uric acid. Urethral calculi (table 4). The urethral stones have nearly the same composition as the ureteral ones. The similarity of nuclei and shells of these stones is marked especially as to minor constituents. Comment. We are presenting no direct experimental evidence of the method of formation of urinary calculi but the following considerations may be of value in the formulation of a hypothesis.
- -·----
388
C. H.
DET.
SHIVERS AND K . P. HENDERSON
It is interesting to note that calcium oxalate was found in the nucleus of 67 per cent of the renal stones, 86 per cent of the ureteral stones, 82 per cent of the vesical stones and SO per cent of the urethral stones. As many of the nuclei contained rather large amounts of calcium oxalate and granting that they had their ongm m the kidney, we were
,.,
,(,
,.,
,,
..'
i>
,,
•
,
1'
.
.... ,,
•-
,_.,s:
•,. •
I
,,
•
,,
,'
,,
'
J.
"
FIG. 26. Vesical calculi TABLE
4.-Chemical composition of urethral calculi PER CENT OF DRY WEIGHT
NO.
SA?o.fPLE OF
WT.
MOIS -
E
E
TURE
.~
·.::0
.§~ J= ' ;;; "'0
u
-
---
--
gnt.
per cent
35 3. 5*
G
1 .1
f \
Shell Nucleus Entire stone
-
"" ~- ~
"""
~o -
Cl
E
~
I m" 2:-S 0
~
-0
..c o. µ0
·~
0 "
p
m"
..c 0.
~
-- -
.'l
"' -;;;
u
~
-
0
" c;'."S
CYST- FlX ANINE BRIN THIN
CR E ATININE
0 ~ .D 0
-""" u
-
28.3 20 .3 1.6 1.1 26.8 1.5 3.2 0 .0 28.3 20.3 1 .2 1.1 25.2 1 .8 3.2 0 .0 19.5 22.2 2 .8 4 . 2 43.8 0 .0 0 .0 0.0 -
---- -
-
-
* Total weight eleven calculi.
impressed with the idea that the pathological process occurring in the wall of the renal papilla, consisting of a subsurface deposit of calcium so beautifully illustrated by Randall, might be due in part to the irritation caused by the excretion of oxalic acid as calcium oxalate. This highly insoluble compound is kept in solution normally by the acid
URINARY CALCULI REQUIRING SURGERY
389
phosphates present in the urine. The normal daily excretion of calcium oxalate is about .02 to .05 gm. The amount of oxalate excreted is increased by the ingestion of certain foods rich in oxalates such as rhubarb, grapes and spinach. Oxalic acid may also be formed from the decomposition of the uric acid in infected urine, and abnormally large amounts may arise from excessive gastric fermenta.tion of carbohydrates and excessive destruction of purines. Wells states that probably the small amount of oxalic acid normally formed does not cause toxic effects although there is evidence that long continued excretion of oxalic acid as calcium oxalate may cause renal lesions. Chambers feels that injury of even slight degree may bring on severe alteration in cells. Mechanical injury of cells while under the microscope results in an apparent increase in the acid reaction of the parts involved. The formation of calcium oxalate as nucleus for calculi may thus be seen to be logical through the prolonged excretion of large amounts which may produce the initial renal lesion and consequent change in cell reaction. The calcium oxalate would then depositeither because the urine contains more than can be normally held in solution by the acid phosphates or because the changed reaction of the cell is favorable for such deposit. SUMMARY
This study includes 49 cases of urinary calculi. Infection was present in all but 2 cases. The predominating organism was the colon Bacillus. In renal calculus a contributing factor to back pressure was found in only 5 cases. No narrowing of the ureter was detected below a stone in any case. In only 2 cases of focal infection did the organisms correspond with the cultures obtained from the urine. Follow-up treatment was carried out in every case. Patients were instructed to report back at stated intervals for an indefinite period. There has been no recurrence of renal or ureteral stones in this group; vesical stones have reformed in 2 instances where the obstruction at the bladder orifice was not completely removed. Nephrostomy drainage was a definite aid in clearing up renal infections. All vesical calculi were found in the presence of infection and with 2 exceptions behind mechanical obstruction.
390
C. H. DET. SIDVERS AND K. P. HENDERSON
Stones composed largely of carbonates were conspicuous by their absence. The most common urinary salts found m this series were calcium phosphate and calcium oxalate.
121 S . Illinois Ave., Atlantic City, N. J . REFERENCES BARNEY, J. DELLINGER AND E . Ross MINTZ : Relation of parathyroid glands to urinary lithiasis. J . Urol., 36: 159, 1936. CHAMBERS, ROBERT, JR.: The visible structure of cell protoplasm and death changes. Am. Jour. Physiology, 43: 1, 1917. HIGGINS, CHARLES C.: Production and solution of urinary calculi: Experimental and clinical studies. J. A. M . A., 104: 1296, 1935. JOLY, J. SWIFT: Stone and Calculous Disease of Urinary Organs, Chapter 2, p. 79. KEYSER, LINWOOD D. : Recurrent urolithiasis: Etiologic factors and clinical management. J. A. M. A., 104: 1299, 1935. PAPIN, EDMOND: Chirurgie du Rein. 2: 572 (chapter 13). RANDALL, ALEXANDER: Initiating lesions of renal calculus. Surg., Gynec. and Obst., 64: 201-208, 1937. - - - AND EDWARD W . CAMPBELL: Alkaline incrusted cystitis. J . Urol., 37: 284, 1937. SHIVERS, CHARLES H. DET. AND CHARLES J . COONEY: Formation of calculi in urethral diverticula of female. Report of case. J . A. M.A., 102: 997, 1934. WELLS, H. G. : Chemical Pathology. W. B. Saunders Co., Philadelphia. 1935, p . 675.
It is our purpose to enumerate the clinical and chemical findings in 49 cases of urinary calculi, and attempt to correlate the findings with the suspected etiological factors. These cases are grouped under 4 headings: ( 1) renal; (2) ureteral; (3) vesical; and (4) urethral. The calculi from 42 of these patients were available and for their quantitative chemical analysis we are indebted to Mr. Herman Brown, chemist to the Research Institute of Cutaneous Medicine, Philadelphia. Etiology. The literature on this subject is so voluminous that we will mention but few of the many investigators. The evidence at hand points to 2 possible methods of urinary stone formation: (1) a metabolic disturbance associated with excessive excretion of urinary crystalloids and an imbalance of the protective colloids; (2) an infection with or without mechanical obstruction. The valuable work of Keyser on hyperexcretory and infectious calculosis and Higgins on avitaminosis as an etiological factor in the production of stone is well known to you all. Since the work published by Barney and Mintz on the relationship of hyperparathyroidism to urinary calculi we have examined the blood calcium and phosphorus in twelve of our group. In no instance did we find an increase in the blood calcium or a decrease in the phosphorus. Joly mentions geographical distribution as a possible etiological factor but is unable to explain the prevalence of stone in one part of a country and the absence in another. The question of the influence of lime salts in drinking water is by no means settled as stone is quite common in Holland where the drinking water is reasonably free from lime salts and is rare in Switzerland where the rocks are calcareous and the water very hard. We find that the drinking water in Atlantic City is a mixture of cedar swamp and artesian. The cedar swamp water contains only .6 part per million of calcium and the combination pond and artesian contains 2 parts per million. The average hotel well contains 9 parts per million of calcium. 1 Read before the annual meeting of the American Urological Association, Quebec, Canada. June 30, 1938.
366
URINARY CALCULI REQUIRING SURGERY
367
The soil in Atlantic and Cape May Counties contains only a very small percentage of lime. Many of the people residing outside of .At· lantic City live in small communities that depend on surface well water to supply their needs. It would appear from our study that the low percentage of lime in drinking water in this locality in no way affects the status of calculi. \Vhen one considers the amount of calcium taken in foods there is no reason to be alarmed about the percentage of lime which is contained in drinking water. In considering the part played by focal infections, 25 patients had infected teeth, 2 were suffering from advanced pyorrhea and 4 from en· larged infected tonsils. None gave a history of any chronic intestinal disorder, except constipation, or of any skin, bone or joint disease. Cultures were not obtained routinely, but in 2 cases with infected teeth the non-hemolytic streptococcus and staphylococcus were present. Case No. 3557, in which the Staphylococcus albus and streptococcus were recovered from the root of an infected tooth, the staphylococcus was cultured from the left kidney which contained a moderate size calculus (qualitative analysis, Atlantic City Hospital). Case No. 6307 in which the non-hemolytic streptococcus was cultured from the root of a tooth, the same organism was recovered from the right kidney. This patient had a calculus in the pelvic portion of the right ureter (fig. 11). The focal infections in the remaining cases did not correspond with the organisms cultured from the urine. Renal calculi. In this series there were 14 cases of which 7 were females and 7 males. The renal involvement was entirely unilateral. In the former group 6 involved the right kidney and l the left kidney. The age incidence in the female group averaged 40 years, the youngest being 26 and the oldest 60. In the male group the right kidney was involved in 5 cases and the left kidney in 2 cases. The average age was 47 years, the youngest was 26 years of age and the oldest 69. Stones were found in the renal pelvis in 7 cases, a branched calculus was present in 3 cases, one patient suffered from a calculus at the ureteropelvic junction and in 3 other cases the stones were found in the calices. Nine showed Colon bacillus infection, 6 of which were present in an acid urine, 2 in an alkaline urine and 1 in a neutral urine. Three cases showed staphylococcus associated with Colon bacillus of which 2 were in an alkaline urine and 1 in a strongly acid urine. In 1 case we cultured a non-hemolytic streptococcus associated with Colon bacilli in a weakly acid urine. It is difficult to determine in any given case whether
368
C. H.
DET.
SHIVERS AND K. P. HENDERSON
the infection found at examination preceded or followed the calculus formation. Renal ptosis was a contributing factor to urinary stasis in 2 cases which could be demonstrated preoperatively. Three cases at operation showed a definite thickening of the pelvic wall close to the ureter which was probably due to irritation caused by the calculus and infection. In the remaining cases obstruction to the urinary outflow was caused by the calculus alone. All patients showed definite improvement in back pressure following the removal of the calculus. None of the pa-
FIG. 1. Papin's technique of nephrostomy
tients in this group had been operated on previously for stone. Nephrectomy was done in 1 case, nephrolithotomy was performed in 4 cases and pelviolithotomy with nephrostomy in 9 cases (after the technique of Papin) (fig. 1) where a hemostat is introduced through the pelvic incision and a Malecot catheter drawn into the pelvis through one of the lower calices. We have followed this technique in most all cases where infection was present and have been very much gratified with our results. In most cases the infection responds readily to this treatment. As a rule the tube is removed in ten days and the fistulous tract heals promptly.
URINARY CALCULI REQUIRING SURGERY
369
Case 1 (calculus No. 6). A female, age 48, with a branch calculus in the right kidney (fig. 2) gave a history of pain for a period of 9 years, frequency of urination and burning. The urine showed many pus cells and was weakly acid in reaction. The organism recovered was Colon bacillus. A quantitative estimation of renal function showed 5 per cent dye output from the right kidney and 35 per cent from the left kidney. A diagnosis of calculus pyonephrosis was made and nephrectomy carried out. After removal, the kidney was incised along its external border from pole to pole and all visible calculi removed. X-ray of the specimen (fig. 3) showed numerous shadows representing small fragments of stone left in the kidney.
FIG. 2. Case 1.
Staghorn calculus in right kidney
This case demonstrates the difficulty one has in removing stone fragments when nephrotomy is done for such a calculus without the aid of fluoroscopy and roentgenographic examination at the time of operation. Case 2 (calculus No. 4). A female, age 31, in whom we did not do a nephrostomy in the presence of infection after removing a calculus from the uteropelvic junction (fig. 4) preoperatively showed a large hydronephrosis with a ptosed kidney (fig. 5). Following pelvioureterolithotomy and nephropexy pelvic drainage was established but proved unsatisfactory and the convalescence was stormy. This patient had complained of pain in the right renal region for the past 6 months. The urine was acid in reaction and culture yielded B. coli. The end result was satisfactory (fig. 6) although it required
370
C. H.
DET.
SHIVERS AND K. P. HENDERSON
repeated ureteral catheter drainage and the internal administration of mandelic acid before the infection entirely cleared up.
Fm. 3. Case 1. A, X-ray of kidney after sectioning, showing numerous small calculi remaining; B, plain x-ray of gross specimen of right kidney after removal of large calculus.
FIG. 4
FIG. S
FIG. 4. Case 2.
Intravenous urogram (45 minutes). Calculus at ureteropelvic junction showing dilatation of right renal pelvis. FIG. 5. Case 2. Intravenous urogram (30 minutes) taken in upright position. Note marked ptosis of right kidney with hydronephrosis.
Cases 2 and 3. These were cases of massive calculous pyonephroses, where the kidneys were densely adherent to the surrounding structures, the calculus
371
URINARY CALCULI REQUIRING SURGERY
was removed and nephrostomy drainage established. shown marked improvement.
Both patients have
FIG. 6. Case 2. Postoperative right pyelogram in upright position. size of pelvis and good position of kidney.
Note decrease in
FIG. 7 FIG.8 FIG. 7. Case 4. Plain film showing calculus in right renal pelvis FIG. 8. Case 4. Preoperative right pyelogram showing large hydronephrosis
Case 4 (calculus B). A male, age 51, gave a history of chronic backache with acute exacerbations involving the right renal area for a period of 10 years. Examination revealed a moderate size calculus in the right renal pelvis (fig. 7) with no dye function. Preoperatively this patient had a urine which was
372
C. H. DET. SHIVERS AND K. P. HENDERSON
weakly acid in reaction, 3 to 4 white blood cells per high power field and 1 to 3 red blood cells. The smears of the sediment were negative for organisms. The blood chemistry was normal. Forty-eight hours after ureteral drainage was established by cathether renal function was active as shown by indigo carmine output. A definite hydronephrosis was visualized (fig. 8). Following pelviolithotomy and nephrostomy (fig. 9) postoperative pyelogram showed a decrease in the size of the pelvis with a normal renal function. Case 5 (calculus No. 2). A woman, age 43, underwent an extensive nephrolithotomy for a branched calculus (fig. 10) because of poor function and infection of the opposite kidney. A small fragment of stone was left in the lower pole (fig. 11). The postoperative pyelogram showed considerable deformity of the pelvis (fig. 12). The renal function was surprisingly good
FIG. 9. Case 4.
Postoperative right pyelogram showing decrease in size of renal pelvis
and with the aid of mandelic acid the infection was reduced to a minimum with a reduction in the size of the x-ray shadow. This patient was treated for urinary infection for a period of 6 years before routine cystoscopic and x-ray examinations were carried out to make a correct diagnosis. The infecting organism was Colon bacillus. Case 6 (calculus No. 5). A female, age 60 years, gave a history of right renal colic over a period of S years. A plain x-ray taken of the kidney 3 years before showed a shadow in the region of the right renal pelvis. At the time of our first examination (fig. 13) we found a stone blocking the outflow of urine from the right renal pelvis with an infected but normal functioning left kidney. The patient was in poor general condition with frequent chills, high temperature and a high leukocyte count. The urine was strongly acid in
URINARY CALCULI REQUIRING SURGERY
Frn.11 10. Case 5. Plain film with ureteral catheters in situ showing calculus occupying left renal pelvis and calices. FIG. 11. Case 5. Plain film, postoperative, showing very faint shadow in lower pole of left kidney. FIG.
FIG. 12. Case 5. renal pelvis.
Postoperative left pyelogram showing considerable deformity of
reaction, contained 17 50 mgms. of albumin, innumerable pus cells and 20 to 30 red blood cells per high power field. The blood urea nitrogen was 33 mgms. per cent and the creatinin 3.4 mgms. per cent. On entrance to the hospital
374
C. H. DET. SHIVERS AND K. P. HENDERSON
she refused operation so we attempted to establish renal drainage by catheter. This was only temporarily successful as the catheter slipped and became obstructed. Consent was given for operation at a time when the patient was almost moribund. The kidney was exposed by lumbar incision; drainage was established by nephrostomy. After incising the kidney at least a pint of purulent urine escaped. The stone could not be palpated. On account of the desperate condition of the patient we were satisfied with drainage alone. She made an uneventful recovery but refused further operative intervention for removal of the calculus. An attempt was then made to dissolve the stone. The pH of the urine was reduced with ammonium chloride, mandelic acid was administered for the colon infection and the renal pelvis was lavaged with
FIG. 13. Case 6. Plain film. vertebra, right side.
½to
Catheter in right ureter, calculus at level of third lumbar
2 per cent solution of phosphoric acid (as recommended by Randall and Campbell) and for a time a continuous flow of phosphoric acid was given through a ureteral catheter. There was a definite decrease in the size of the calculus (fig. 14). Its outer layers almost entirely disappeared leaving princi:Qally the nucleus which failed to reduce further in size. The stone was later removed by the sense of touch (fig. 15) through the nephrostomy opening, using Randall stone forceps. Convalescence was satisfactory. Case 7 (calculus Group 1). A female, age 30, was the only patient we lost in this group. She presented multiple calculi occupying the calices of the right kidney with a third degree ptosis (fig. 16). Some of them were literally filled with these stones. The kidneys functioned normally as shown by individual phthalein tests. A pelviolithotomy was unsuccessful as most of the
URINARY CALCULI REQUIRING SURGERY
375
stones were closely packed and densely adherent to the lining of the calices, To facilitate their removal an extensive nephrotomy was necessary. Grossly the parenchyma was normal throughout. There was practically no blood
FIG. 14 FIG. 15 FrG. 14. Case 6. Plain film after removal of nephrostomy tube, and insertion of ureteral catheter. Calculus shows a decrease in its outer layers, leaving principally nucleus. FIG. 15. Case 6. Plain film after removal of calculus through nephrostomy opening. Right ureteral catheter in situ,
Fm. 16. Case 7. Plain film with ureteral catheters in situ, showing ptosed right kidney with many small calculi in calices.
lost during the operation and nephrostomy drainage established. The operation took about 35 minutes and the patient was in good condition when she left the table. Directly afterwards, however, the pulse became rapid and
376
C. H.
DET.
SHIVERS AND K. P. HENDERSON
was uncontrollable. A temperature followed and the patient died within 48 hours. There was no postoperative hemorrhage at any time as shown by blood count and clinical observation. The drainage from the renal pelvis was clear. Autopsy was refused. We have not been able to give a satisfactory explanation for the cause of death in this case. Certainly an extensive nephrolithotomy with subsequent renal damage is not an operation of choice where the opposite kidney is normal. One might question the surgical removal of some of these calculi because of their size. No cases presenting small renal stones were subjected to operation without first giving them an opportunity to pass the calculus following ureteral dilatation. In every case definite evidence of urostasis with infection was present. Cases we did not operate on immediately following their first cystoscopic and x-ray examination were kept under close observation and when evidence of back pressure increased we advised immediate surgical intervention. There has been no recurrence in this group. Ureteral calculi. There were 7 cases in this group, 2 men and 5 women. In the male group, 1 calculus was removed from the right lumbar ureter and the other from the intramural portion of the left ureter. In the female group the calculi were found and removed from the pelvic portion of the left ureter. Infection, due to B. coli, was pres-· ent in all but one in which the non-hemolytic streptococcus was cultured. Four cases showed urine weakly acid in reaction and 3 cases were strongly acid. The average age in the male was 44 years, the youngest being 32 and the oldest 57. In the female group the average age was 36 years, the youngest being 20 and the oldest 56. All of these patients recovered promptly from operation and none to date have had any recurrence. The interval in 2 cases has been 4 years, in 2 cases 1 year, in 1 case 4 months, and in 2 cases 3 months. Case 8 (calculus No. 12). A woman, age 56 was admitted to the Medical Service of the Atlantic City Hospital because of chills and fever. Her previous history was negative except for an attack of pain in the region of the left kidney about 6 months previous to admission with a slight recurrence shortly before admission. During her stay in the hospital she complained of no pain at any time. She was an obese individual and nothing was detected on physical examination. Because of the persistent pyuria we were requested to see the patient. We advised an intravenous urogram which shows (fig. 17)
URINARY CALCULI REQUIRING SURGERY
377
FIG. 17. Case 8. Intravenous urogram, 5 minutes, preoperative. No excretion from left CalclJlus in lower left ureter. Shadow of left kidney shows a definite increase in size.
FIG. 18. Case 8. in left ureter.
Right pyelogram showing normal pelvis.
Calculus at tip of catheter
378
C. H.
DET.
SHIVERS AND K. P. HENDERSON
prompt visualization of the right renal pelvis, and a triangular shaped shadow in the pelvic portion of the left ureter. No excretion of dye was detected from the affected side and the shadow of the left kidney showed a definite increase in size. The patient was transferred to the Urological Service. At cystoscopy the first attempt to pass the obstruction, which was 5 cm. from the ureteral orifice, was unsuccessful (fig. 18). Indigo carmine output from the right kidney was prompt with none from the left. No drainage was established through the left catheter. On a second attempt the obstruction was passed
FIG. 19 FIG. 20 FIG. 19. Case 8. Left pyelogram, preoperative, showing hydronephrosis. Calculus in left ureter at level of posterior inferior spine of ilium. FIG. 20. Case 8. Postoperative left pyelogram showing decrease in size of renal pelvis.
and the catheter introduced to the renal pelvis. 80 cc of purulent urine were removed. The pyelogram showed a large hydronephrosis (fig. 19), the catheter was left in situ for several days, the function of the kidney showed marked improvement, dilatation of the ureter was repeated and the patient given a fair chance to pass the calculus. On account of the damage already done to the left kidney we felt that time was an important factor and removed the stone surgically. Normal function has been established (fig. 20) with a decrease in the size of the renal pelvis.
URINARY CALCULI REQUIRING SURGERY
379
Retention of urine in the renal pelvis most commonly occurs in association with stones that have a part reaching into the ureter or from stones that are in the ureter itself. The case cited illustrates the damage which may occur from a so-called silent ureteral calculus. In none of these cases did we detect any obstruction in the ureter below the calculus. A few of the stones showed sharp projections protruding from the body which were embedded in the mucosa of the ureter and accounted for the fact that they remained largely stationary after repeated ureteral dilatation. We do not subscribe to the school advocating metal cystoscopic ureteral instruments for the removal of ureteral calculi, (1) because of the suffering the patient may have to undergo before the calculus finally
FIG. 2L Plain film showing vesical calculi in presence of prostatic enlargement
passes and (2) because of the injuries to the ureteral wall which occasionally occur. After operation, patients with renal or ureteral calculi are requested to report at stated intervals for proper follow-up treatment. If there is no evidence, after a time, of infection or obstruction the examination may consist only of a urinalysis. In all patients with focal infections such as teeth and tonsils an attempt was made to correct their infection either before or within a short period following operation. Vesical calculi. In this group we had 26 cases. All of the calculi were found in the presence of infection and, with 2 exceptions, behind mechanical obstruction. In all patients, culture 0£ the urine yielded
380
C. H.
DET.
SHIVERS AND K. P. HENDERSON
B. coli. Ten calculi were found in the presence of alkaline urine, 9 in acid urine; 5 were found in neutral urine and 2 in weakly acid urine. We may further subdivide this group into those cases in which vesical calculi were found in the presence, (1) of adenomatous hypertrophy, (fig. 21) (2) contracture of the vesical neck; (3) urethral strictures, and (4) transvesical drainage. Case 9 (calculus No. 15). A moderate size calculus was found in the bladder of a colored woman, aged 55 (fig. 22). The urethra was literally filled with filiform strictures. Culture of the urine, which was slightly alkaline, yielded
Fm. 22. Case 9. Plain film showing calculus in bladder in presence of multiple filiform strictures of urethra.
B. coli. Following transvesical removal of the calculus and urethral dilatation, the patient made a complete recovery.
We feel that a certain number of these calculi were formed in the kidney. However, only 1 patient gave a history of left renal colic 6 months prior to admission at which time a small irregular dark calculus (No. 22) was found. Certainly stones may slip down from the kidney without producing any marked symptoms and if obstruction is present at the vesical neck or within the urethra they may attain considerable size.
In l case a calculus was reported in its formative stage attached to an unabsorbed suture in the anterior vesical wall. There was no obstruction at the vesical outlet or in the urethra.
URINARY CALCULI REQUIRING SURGERY
381
Case 10. A hoy 9 years of age who was admitted to the hospital for correction of a hypospadias, developed a stone (No. 36) in the bladder during the time he was wearing a suprapubic drainage tube for the purpose of diverting the stream. At the time suprapubic drainage was established there was no urinary infection and the bladder was entirely negative for stone. Because of the abundance of phosphates in the urine it was necessary to change his tube weekly. His bladder was irrigated twice daily. He wore the tube for several months. A stone was suspected which was proven by x-ray shortly before the tube was permanently removed. Cultures of the urine showed the R coli. The urinary infection promptly cleared up after the removal of the stone and tube.
In none of the patients presenting calculi with obstruction where the obstruction was properly removed did the calculus recur even though
3S 9
2
3
FIG. 23. Case 11.
4
5
6
Urethral calculi
the infection was not entirely cleared up. We had 2 patients in which stones reformed. In both instances some obstruction remained Rt the vesical outlet. There was 1 death in this group from advanced renal infection due to B. coli. Urethral calculi were found in 2 cases, 1 male and 1 female. Case 11, (calculus No. 35) (fig. 23). A colored male, age 39, suffered for years from urethral strictures. A fistulous tract opening in the perineum was present. Calculi were shown by x-ray and could be detected by palpation. The stones were found in the bulbous portion of the urethra which was markedly dilated. The infection was severe.. The urine was neutral in reaction and cultures yielded B. coli. Case 11 (calculus G). A colored female, age 41, in whom a stone was found
382
C. H.
DET.
SHIVERS AND K. P. HENDERSON
in a diverticulum of the urethra, was previously reported by Shivers and Cooney. We felt that the calculus formed in a pre-existing diverticulum as the patient gave no history of urinary symptoms and the urine which was alkaline was free of infection. There has been no recurrence of urethral stones following dilatation or surgery. Quantitative chemical analysis of the calculi. Quantitative determinations were made on the dried powdered samples for calcium, magnesium, ammonium, phosphorus, uric acid, oxalic acid and carbonic acid. These tests were made by adaption of micromethods used in blood chemistry (as little as SO mgm. of sample may be used). Qualitative tests were
FIG. 24. Renal calculi
also made of the less frequently occurring constituents such as cystine, fibrin, xanthin and creatinin. The results of the latter tests, as shown in the charts, indicate that they are only exceptionally found as impurities. The sample taken for analysis as nucleus consisted of that center portion of cut stone in which on gross examination no further evidence of subdivision could be observed. In more than one-third of the stones the nuclei were poorly defined. In nearly half the stones the gross physical appearance of the two areas was quite di:ff erent. Many stones exhibited nuclei of powdered or granular texture with hard, dense shells; in others the reverse condi-
383
URINARY CALCULI REQUIRING SURGERY
1.-Chemical composition of renal calculi
TABLE
---P~ER_c_E_N·_r_oF_D_R_Y_w_Er_G-RT_ _ _
NO.
WT.
SAMPLE OF
.§ I ·2§
MOIS-
TURE
if)
a)
'-'"d
0
~-§
;;;
- - -------1--- --- per gm. cent
-
-
~ -<
--- -
-
- - ~ · - - - - - - -----
A
7 .O
f l
Shell Nucleus
1. 3 5. 0 0. 0 1 . 01' 0 . 7 0 .0 0 .0 0 . 8
B
f 24 l
Shell Nucleus
14.7143.7 0.0 0.0 2.741.0 0.0 0.0
C
3.5 {
Shell Nucleus
2.040.7 0.2 0.0 32.0 0.01 7.6 0.0 17 . 4 35 . 31 1 . 2 0. 0 30 . 7 0. 0 5 . 9 0 . 0
Shell Nucleus
5.940.410.8 0.0 31.1 0.0 4.3 3.3 4.3 40 .4i 1.2 0.0 33. 9 0.0 4.3 3 .5
( Shell 6.5 \ l Nucleus
4.0 44.81_ 0.0 o.o 31.1 o.o 8.6 2.2 4. 3 45 . 8 0 . 0 0 . 0 29 . 5 0 . 0 4 . 3 3 .4
I
fl
5 .0
3
0. 0 28. 8 38. 0 2. 8 0 . 0 28 . 8 33 . 0 2 . 2
I
2 ·5 \ 2
I
Shell Nucleus
0.0 0.055.8 0.0 2.61 0.054.3 0.0
I
I
1
1
43.2 ' 0.0[I 2.9!I 6.2 30.0 0.0 0.0 0.0 44.9 2.313.216.8 32.0 0.0 0.0 0.0
+ +
+ +
'·
2sf
4
0
Shell ( Nucleus
2.1 39.2I 1.5j 2.01 12.8 o.olzo) o.o
5
0 .45j Shell l Nucleus
3 :136.3' 0.01 0 0 16.01 0.0[2~.010.0 1 141.41 o o! o.o 14.2! 0.0 2.).9! o.o
1
1
2.8,35.81' 0 9\ 2.4\ 15.1 0.019.0, 0.0
I
i
I
i
I
I
I
1
6
f l
15
D
0 3
E
O
Shell Nucleus
i
1
Shell
i_\ Nucleus
.
6.239.2[ 2 8\ 0.8 30.4\ 0.01 O.OI 1.8 14.134.81 3.21 0.6, 30.91 0.0! o.o, 1.4 41.5 1 2.21 1.9) 3.9i 33 5\ o 0 0.0 1· 2.2 40.5 3.4. 1.8\ 3.6[ 30.t 4.8 0.0 3.4
I
1
17JI
I · \[ I F
i 1
'
Shell Nucleus
O 08 -
•
f]
l
Shell Nucleus
I
\
!
I
42.81 2.2i 2 01 4.oi 36.li 0.0 3.010.0 43.4! 4.5( 4.01 30.7 1 3.7 6.2 0.0
1.7;
i
!
I
:
'
I
.
40.0I 2.0 1 1.6) 1.9! 34.41 o.ol 3.01 1.8 41.1 3.8 1 1.5\ l.7! 3.2! 4.0 4.2\ 1.4 1
--
-
--
-
--
- I ---- [ --
I
1
! -
-
-
I -
I
--
-
!
\
I -
I -
i -
-
1
-
i [ I I
-
i --
--'-'- - - - - - - ' - - - - -
tion existed. In some of the calculi no apparent differences could be noted in the cut area. Renal calculi (fig. 24, table 1). The largest stone m this group weighed 22 gm. and the smallest .25 gm. In observing the following
384
C. H.
DET.
SHIVERS AND K. P. HENDERSON
tables one will see that despite physical dissimilarity, the chemical constitution of both the shell and nucleus of each calculus in the renal and ureteral groups are relatively similar. This chemical similarity despite physical dissimilarity is evident even in the minor constituents of these stones so that it would appear that the mechanism responsible for the initial formation of the nucleus continues unchanged throughout the life of the stone. In those calculi formed in sterile urine infection prob2.-Chemical composition of ureteral calculi
TABLE
PER CENT OF DRY WEIGHT
I
NO.
SAMPLE OF
WT.
I I MOIS-: i' s I TURE I s " I -~ " '
l
~
0
§~ O ~
-_,_,
~o.
J 1~
-§] ~]
8
s:::i
0
'"d
-~~
- -- - - - - -;;; -- - --i-- -1- -- - - - 1 gm.
7 1. 4
I
cent
f l
Shell Nucleus
I
I
I
I
9.5 36 9 0.3 0 0 20.6 0.01 7.9/ 4.3/ 6.336.9 0.2 0.017 20.017.912.81 1
1
1
I 12.137.01
I
I
I
8 0 _19{
Shell Nucleus
2.2 3.6 135.812.8 5 8. 5.6 1 14.433.0, 2.6 3.235.03.1 5.0' 4.8
9 0.2 {
Shell Nucleus
2.735.8/ o.o o.o 0.0,0.0 41.7 o.o 1.937.ol o.o o.o o.°j°.0(5.2 o.o
Shell Nucleus Entire stone Shell Nucleus
1.7 31.2, 0.010.018.44.9121.6 0.0 2.230.210.0, 0.0~20.8~6.1/11.1 0.0 4.0 43.6 0.8 o.0;32.0.0.01 8.6 o.o 1 2.0,35.8 1.11 0.01 0.0,0.0140.3 0.0 2.oi37.o 1.3 0.01o.oro143.210.0
I
I
1
1
10 0. 6 { 11 0.05
12 0.24{
13 0. 2 {
Shell Nucleus
1
+ +
1
14.4/28.0 0.7 0 0122.2,0.710.010.0, 17.5j26.8 0.8 0.0;23.2i°-9 0.01 0.01
ably occurred shortly before the patients were examined by us which would account for the absence of change in the shell of the stones. Only 1 stone was found to be relatively pure. Both the shell and nucleus of stone B consists of practically pure calcium oxalate with but a very small proportion of phosphate present in the nucleus that is not evident in the shell. All the other calculi in this group contained large amounts of calcium in both shell and nucleus combined with phosphate and oxalate with the exception of stone A and No. 3 which contain a small percentage of calcium in both the nucleus and shell. Stone A is a mixture of fixed alkali urate and oxalate and the close chemical
URINARY CALCULI REQUIRING SURGERY
385
similarity of its shell and nucleus is to be noted. Stone No. 3 is a mixture of magnesium, ammonium and fixed alkali phosphate. The low values for carbonate seen in this chart are evident in the other charts of this series. It appears that carbonate plays but a minor role in stone formation. It is noteworthy that stone A alone of the entire series shows uric acid as a major constituent while all the other calculi, with the exception of D, E and F are free of uric acid. Ureteral calculi (fig. 25, table 2). The largest ureteral stone removed weighed 1.4 gm. and the smallest .05 gm. Stone No. 9 is practically pure calcimn oxalate in both shell and nucleus. Stone No. 12 is a calcium oxalate stone mixed with about 2 per cent magnesium oxalate.
7
I()
II
I 3
FIG. 25. Ureteral calculi
It is interesting to note that the only single-constituent stones found in this series were composed of calcium oxalate. All tbe other stones are essentially mixtures of calcium phosphate and oxalate with the exception of No. 8 which also contains considerable ammonium phosphate. Vesical calculi (fig. 26, table 3). The largest stone in this group weighed 83.5 gm. and the smallest .3 gm. A portion of the vesical stones, unlike the renal and ureteral, show a definite difference between the shell and the nucleus. Only in those cases in which the entire stone formation occurred subsequent to infection are the analyses of both shell and nucleus substantially the same (Nos. 14, 15, 20, 21, 25, 26, 28, 29, 30, 31, and 36). These stones probably formed in alkaline,
TABLE
3.-Chemical composition of vesical calculi PER CENT OF DRY WEIGHT I
~o.
SAUPLE OF
WT.
E
MOIS-
TURE
s"' -3~ ~ '";;
----
-----
u
~-
~
-~
~~ on·~ ..,,o
"'~
""
---
s ·a"0 s s <
w"
e~ ~
0
.,:o
o.~
w
~
0"
-" 0.
p.,
~
] -~"' ;:5
--- --
~:-s"
2
0
"' cl
CYSTFIBRIN INE
XANTHIN
CRE.., ATININE
K
..0 0
~~
K
u
0
~-
-
~- ~- ~-
----
per cent
gm.
14
( Shell 22. 9132. 3 1.5 0.0 27.3 0.0 2.5 3.2 34.0 \ Nucleus I 27.527.6 1.1 3.5 27.3 0.5 1.8 4.3
15
Shell 16.0 { Nucleus \
-
-
-
-
-
-
-
-
-
!
Shell l Nucleus
1.8 0.0 0.0 4.5 8.1 0.0 0.0 0.0
0.0 60.0 0.0 0.0 0.0 56.8 0.0 0.0
-
-
-
-
(
1.0 0.0 0.0 0.0 0.9 0.0 0.0 0.0
0.0 64.8 0.0 0.0 0.0,64.8 0.0 0.0
-
-
-
-
Shell Nucleus
22.3 28.0 1.4 1.3 32.8 1. 7 2.9 1.5 2.1 37.0 0.0 0.0 6.6 0.8 37.4 0.0
-
-
-
-
-
Shell Nucleus
20.5 11.2 1.3 6.0 30.3 31.2 11.0 0.8 5.9 33.6 0.3 0.5 4.6 0.0 43.2 0.0
-
-
-
-
-
Shell
-
-
-
-
-
-
-
-
-
+ +
16
1.6 [
17
29.0 (
18
72.5 {
Shell
\ Nucleus
\ (
19
6.8
13.1 37.1 1.1 1.1 32.3 0.8 2.9 4.6 13 .4 35.8 1.4 0.8 27.3 0.8 2.2 4.5
j \
-
20
83.5 { Nucleus
18.8 28.0 2.1 1.5 32.4 0.0 1.4 2.5 13.9 35.8 0.7 0.4 34.1 0.0 1.4 2.2
-
21
Shell 15_0 { Nucleus
31.4 11.2 3.0 3.1 31.2 0.0 o.o] o.5 23.6 22.4 2 .4 1.4 24.4 0.014.410.5
-
(
22
0.4
t
Shell Nucleus
23
15 .6
l(
24
-
-
-
-
-
-
2 .4 28.0 0.7 1.8 23.7 0.0 4.3 2.4 4.9 37.0 0.5 0.9 12.7 0.0 28.8 2.0
-
-
-
-
24.6 4. 7 0.0 4.9 30. 7 0.0 1.6 0.0 38.2 11.8 1. 7 5.2 29.4 1. 2 2.1 0.0
-
-
-
-
Shell
41.3 4. 7 0.0 5.3 29.4 2.5 3.1 0.0 17.2 8.2 0.0 11. 7 12.3 6.8 1.6 0.4
-
-
+ +
-
Shell Nucleus
18.8 35.9 0.0 0.0 31.6 0.0 1.6 2.3 38.2 25.9 1.2 3.9 29.5 2.5 1.2 2.0
-
-
-
--
2.6 17.9 1.4 7.6 21. 7 24.4 27.4 1.4 2.7 11.8 1.6 9 .1 7.8 27.8 21.6 1.9
-
-
-
-
-
Shell Nucleus
l0.8 33.6 1.2 0.0 25.7 0.0 2.2 3.9 6.3 31.4 0.8 0.0 7.8 0.0 36.0 3.5
( Shell l Nucleus
0.4 \
I
Shell
46.0 )_ Nucleus
26
30.0 { Nucleus
27
52.0
t (
I
-
6.8 0.0140.3 0.0 7.5 0.0 41.8 0.0
25
28
1
-
Shell
0.5 { Nucleus
1.6 33.6 0.8 0.0 1.1 35.8 0.5 0.0
386
-
-
387
URINARY CALCULI REQUIRING SURGERY TABLE
----~ ~-
3.-Concluded
--
NO.
WT.
SAMPLE OF
Is
MOISTURF.
s"'
.2
~ a;,
]] cl 0
u
SJ]
"'0
:::: -
~
.2
I
..c,o
8
m~
0
a
-<
---
per
gm,
m"
2~ 0 k
~
a.~
0"
"O
·g u
.,.,..c, 0.
i§
---
--
I I
I
PER CENT OF DRY WEIGB:T ---~--~-
-;,"
"' k
0
§]" ~:.a u --
CYST- F BRI INE
•l
) XAN-
N' THIN
CRE-
ATIWINE
I
.0 0
I
-1--
cent
lf
Shell Nucleus
26.2 20.2 1 .1 3.1 23.0 5.0 3.4 0.0 33.8 24.6 l.3 2.1 18.9 0.0 8.9 0.0
r
Shell
14.9 34.7 1.8 2.1 30.1 2.3 4.3 3.0 18.4 28.0 1.5 2.1 28.5 3 6 4.3 2.5
0.8 \ Nucleus
( Shell
20.4 28.0 1.8 0.8124.5 1.51 5 .8 4.9 8.5 31.4 0.4 0.0 22.3 1.2 2.8 4.6
fl i Nucleus Shell
3.3 37.0 0.0 0.0 21.0 0.0 14.4 0.0 2.7 37 .0 0.0 0.0 5.2 1.8 30.3 0.0
29
3.2
30
1.0l Nucleus
31
32
O. S
33
1.2{
Shell Nucleus
0.8 0.0 0.0 0.0 2.3 3S.8 0.0 0.0
0.0 64.610.0 0.0 0.01 4.4145.2 0.0
34
0. 7
lf
Shell Nucleus
1.0 4.5 0.0 0.0 1.0 0.0 0.0 0.0
3.0152.0j 0.01 0.0 0.0:56.2i 0.0 0.0
36
2.
f l
Shell Nucleus
1.51
33.9 16.7 2 32.4 20.3 1.01 2.
36.8,i 0.01i 0.0 3.3 32.ol o.o o.o 2 6
+
--
-~------
infected urine. The analyses indicate progressive alkalinity with increased amounts of ammonium salts in the shell. Calculus Nos. 16, 18, 19, 22, 23, 24, 32, and 34 probably began formation in uninfected, acid urine and, as a result of the stone formation, the urine became infected with resulting deposits of phosphates followed by ammonium salts as the urine became more alkaline. The nuclei of these stones are calcium oxalate with two exceptions (16 and 34) which have uric acid nuclei. To be noted is one pure uric acid stone, No. 17, and one, No. 33, in which the nucleus is pure calcium oxalate and the shell uric acid. Urethral calculi (table 4). The urethral stones have nearly the same composition as the ureteral ones. The similarity of nuclei and shells of these stones is marked especially as to minor constituents. Comment. We are presenting no direct experimental evidence of the method of formation of urinary calculi but the following considerations may be of value in the formulation of a hypothesis.
- -·----
388
C. H.
DET.
SHIVERS AND K . P. HENDERSON
It is interesting to note that calcium oxalate was found in the nucleus of 67 per cent of the renal stones, 86 per cent of the ureteral stones, 82 per cent of the vesical stones and SO per cent of the urethral stones. As many of the nuclei contained rather large amounts of calcium oxalate and granting that they had their ongm m the kidney, we were
,.,
,(,
,.,
,,
..'
i>
,,
•
,
1'
.
.... ,,
•-
,_.,s:
•,. •
I
,,
•
,,
,'
,,
'
J.
"
FIG. 26. Vesical calculi TABLE
4.-Chemical composition of urethral calculi PER CENT OF DRY WEIGHT
NO.
SA?o.fPLE OF
WT.
MOIS -
E
E
TURE
.~
·.::0
.§~ J= ' ;;; "'0
u
-
---
--
gnt.
per cent
35 3. 5*
G
1 .1
f \
Shell Nucleus Entire stone
-
"" ~- ~
"""
~o -
Cl
E
~
I m" 2:-S 0
~
-0
..c o. µ0
·~
0 "
p
m"
..c 0.
~
-- -
.'l
"' -;;;
u
~
-
0
" c;'."S
CYST- FlX ANINE BRIN THIN
CR E ATININE
0 ~ .D 0
-""" u
-
28.3 20 .3 1.6 1.1 26.8 1.5 3.2 0 .0 28.3 20.3 1 .2 1.1 25.2 1 .8 3.2 0 .0 19.5 22.2 2 .8 4 . 2 43.8 0 .0 0 .0 0.0 -
---- -
-
-
* Total weight eleven calculi.
impressed with the idea that the pathological process occurring in the wall of the renal papilla, consisting of a subsurface deposit of calcium so beautifully illustrated by Randall, might be due in part to the irritation caused by the excretion of oxalic acid as calcium oxalate. This highly insoluble compound is kept in solution normally by the acid
URINARY CALCULI REQUIRING SURGERY
389
phosphates present in the urine. The normal daily excretion of calcium oxalate is about .02 to .05 gm. The amount of oxalate excreted is increased by the ingestion of certain foods rich in oxalates such as rhubarb, grapes and spinach. Oxalic acid may also be formed from the decomposition of the uric acid in infected urine, and abnormally large amounts may arise from excessive gastric fermenta.tion of carbohydrates and excessive destruction of purines. Wells states that probably the small amount of oxalic acid normally formed does not cause toxic effects although there is evidence that long continued excretion of oxalic acid as calcium oxalate may cause renal lesions. Chambers feels that injury of even slight degree may bring on severe alteration in cells. Mechanical injury of cells while under the microscope results in an apparent increase in the acid reaction of the parts involved. The formation of calcium oxalate as nucleus for calculi may thus be seen to be logical through the prolonged excretion of large amounts which may produce the initial renal lesion and consequent change in cell reaction. The calcium oxalate would then depositeither because the urine contains more than can be normally held in solution by the acid phosphates or because the changed reaction of the cell is favorable for such deposit. SUMMARY
This study includes 49 cases of urinary calculi. Infection was present in all but 2 cases. The predominating organism was the colon Bacillus. In renal calculus a contributing factor to back pressure was found in only 5 cases. No narrowing of the ureter was detected below a stone in any case. In only 2 cases of focal infection did the organisms correspond with the cultures obtained from the urine. Follow-up treatment was carried out in every case. Patients were instructed to report back at stated intervals for an indefinite period. There has been no recurrence of renal or ureteral stones in this group; vesical stones have reformed in 2 instances where the obstruction at the bladder orifice was not completely removed. Nephrostomy drainage was a definite aid in clearing up renal infections. All vesical calculi were found in the presence of infection and with 2 exceptions behind mechanical obstruction.
390
C. H. DET. SIDVERS AND K. P. HENDERSON
Stones composed largely of carbonates were conspicuous by their absence. The most common urinary salts found m this series were calcium phosphate and calcium oxalate.
121 S . Illinois Ave., Atlantic City, N. J . REFERENCES BARNEY, J. DELLINGER AND E . Ross MINTZ : Relation of parathyroid glands to urinary lithiasis. J . Urol., 36: 159, 1936. CHAMBERS, ROBERT, JR.: The visible structure of cell protoplasm and death changes. Am. Jour. Physiology, 43: 1, 1917. HIGGINS, CHARLES C.: Production and solution of urinary calculi: Experimental and clinical studies. J. A. M . A., 104: 1296, 1935. JOLY, J. SWIFT: Stone and Calculous Disease of Urinary Organs, Chapter 2, p. 79. KEYSER, LINWOOD D. : Recurrent urolithiasis: Etiologic factors and clinical management. J. A. M. A., 104: 1299, 1935. PAPIN, EDMOND: Chirurgie du Rein. 2: 572 (chapter 13). RANDALL, ALEXANDER: Initiating lesions of renal calculus. Surg., Gynec. and Obst., 64: 201-208, 1937. - - - AND EDWARD W . CAMPBELL: Alkaline incrusted cystitis. J . Urol., 37: 284, 1937. SHIVERS, CHARLES H. DET. AND CHARLES J . COONEY: Formation of calculi in urethral diverticula of female. Report of case. J . A. M.A., 102: 997, 1934. WELLS, H. G. : Chemical Pathology. W. B. Saunders Co., Philadelphia. 1935, p . 675.