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A Modified Pyeloplasty for the Correction of Hydronephrosis Due to Extrinsic Obstructions at the Ureteropelvic Junction: A Case Report
THE JOURNAL OF UROLOGY
Vol. 60, No. 5, November 1948 Printed in U.S.A.
A MODIFIED PYELOPLASTY FOR THE CORRECTION OF HYDRONEPHROSIS DUE TO EXTRINSIC OBSTRUCTIONS AT THE URETEROPELVIC JUNCTION A
CASE REPORT
BEN KLOTZ
According to Hinman the subject of hydronephrosis is of greatest importance to the practicing clinician and surgeon because it is one of the commonest characteristics of disease of the genito-urinary system. From a study of 33,360 necropsies, Bell concluded that hydronephrosis is the most common form of renal disease. Not only because of its common occurrence but also because it is frequently found to exist bilaterally (Munger; Sargent) the choice of radical (nephrectomy) or conservative treatment becomes very often an important matter. The development of the surgical treatment of these obstructions at first followed the principles set forth by the general surgeons in their treatment of obstructions at the gastroduodenal junction. It was to be expected that urological surgeons would develop operative procedures of their own to correct obstructions at the ureteropelvic junction. It would be repetitious to list these operative procedures here for they have ceen repeatedly mentioned and classified by others (Dodson; Gibson; Lubash; Moore). Twenty-five years ago Runner stated: "In dealing with a mechanism as delicately balanced as is the ureteropelvic junction, and particularly when that mechanism has been badly disarranged by disease, one hesitates to lay down hard and fast rules. Each case differs from the preceding one in the problems presented and the surgeon should approach these problems with an open mind, ready to adopt the course that seems best fitted for the individual case." These sound remarks from a master surgeon are true even today. The procedure of choice for the individual surgeon still must depend upon his own inclination, belief, judgment, experience and resourcefulness (Davis; Deming; Henline and Menning; Quinby; Sargent; Walters, Cabot and Priestley). The modification herein described adopts, first, the principle of partial resection of the redundant pelvis; and secondly, the principle of preservation of the ureteropelvic junction. It was applied to a case in which the pelvis sagged medially and below the extrinsically obstructed, normally placed, ureteropelvic junction. CASE REPORT
L. H., a male aged 23, was admitted to the U. S. Naval Hospital, San Francisco, November 4, 1945, complaining of pain in the right flank, nausea and vomiting of several hours' duration. He stated that he had had three similar attacks since 1942. He had never passed any stones or blood. The physical examination in general was not significant. The right kidney was lower than normal but not tender. The blood pressure was 132/82. The urine showed 2 706
MODIFIED PYELOPLASTY FOR HYDRONEPHROSIS
707
plus albumin, a rare pus cell and 1-2 red blood cells per high power field. A preoperative phenolsulphonphthalein test was not recorded. Intravenous urograms in the upright position (25 minutes after injection) showed renal ptosis with angulation at the ureteropelvic junction on the right side. Both ureters, left pelvis and calyces were normal. The right pelvis and calyces were markedly dilated (fig. 1, A). Retrograde pyelography was done December 8, 1945. Thirty-five cubic centimeters of rather clear urine were aspirated from the right kidney. When centrifuged this showed several pus cells per high power field. While supine about the same amount of 20 per cent Skiodan was injected' through a Luer syringe and needle (fig. 1, B). The
Fm. 1. A, November 13, 1945. Intravenous pyelogram, upright, 25 minutes after injection. B, December 8, 1945. Retrograde pyelogram, supine, after the injection of 30 cc. Note absence of backflow. C, December 8, 1945. Retention film after being upright for 10 minutes.
ureteral catheter was withdrawn, the patient was immediately placed in the upright position, and 10 minutes later a film (fig. 1, C) revealed findings similar to those in fig. 1, A. He had no pain whatsoever during or any time after the injection. On December 12, 1945, under spinal anesthesia, the right kidney was exposed through a lumbar incision. After severing a large vein which obstructed the ureteropelvic junction, the kidney was easily delivered. The ureteropelvic junction, the adjacent ureter and pelvis were surrounded by old, dense adhesions several millimeters thick. Free of adhesions, the ureteropelvic junction was wide and not thickened. The striking thing was the way the aberrant vein had caused the pelvis to sag medial to and belovv the ureteropelvic junction (fig. 2, a).
708
BEN KLOTZ
A long Kelly clamp was placed somewhat obliquely across the medial border of the pelvis in such a manner as to include the border of the portion that sagged below the ureteropelvic junction. A knife was passed along the under side of the clamp. The remaining pelvis was still larger than normal and its lowermost portion still sagged below the ureteropelvic junction. This junction showed no intrinsic narrowing because the closed end of a Kelly clamp passed through it easily (fig. 2, b). The opened pelvis was next partially closed from above downward with a continuous suture. This suture ended at a point where repeated trial approximations of the lower portion achieved the elimination of the sag (fig. 2, c). At the proper level the sagging portion of the pelvis was anchored with one mattress suture that started and ended on either side of the completed vertical suture line. Now the sag was eliminated and the ureter came off at a normal angle. But this left an opening almost horizontal to the above vertical
;f
~~-
'i
Fm. 2. Scheme: a, Operative findings and line of incision. b, Redundant pelvis resected. c, d, e, Method of closure. f, Method of drainage preferred.
line. The puckered ends of this transverse opening were leveled off with scissors and closure was completed with interrupted sutures (fig. 2, d, e). Chromic 00 catgut was used on the pelvis and none passed through the mucosa. Through a small opening left in the very uppermost end of the vertical suture line, a No. 7 whistle-tip ureteral catheter was passed into the pelvis and about 10 cm. down the ureter (fig. 2, f). Finally, a vertical pyelotomy almost 2 cm. long was made on the anterior surface about 1 cm. away from both the vertical and transverse suture lines. No catheter or tube was placed in this pyelotomy and no nephrotomy was made. The kidney was suspended high by means of a purse-string suture of No. 1 plain catgut taken through Gerota's capsule and anchored posteriorly below the twelfth rib in the region of the costovertebral ligament. Two cigarette drains were placed within Gerota's capsule down to the renal pelvis The wound was then closed in layers with No. 1 chromic catgut. The patient voided well during the first 24 hours and the urinary drainage through the wound was moderately profuse during this period. By the end of
MODIFIED PYELOPLASTY FOR HYDRONEPHROSIS
709
24 hours the temperature rose to 103 F. It gradually returned to normal by December 17. On this date one cigarette drain was removed. For the next 3 days the highest temperature was 100 F. On December 20 the urinary drainage from the wound was more profuse and for the first time he complained of pain. Upon removal of the remaining drain and the catheter from the ureter, his pain ceased dramatically. From then on there was no more urinary drainage. Numerous pus cells and red cells were found in the urine after December 24. The pyuria did not improve with penicillin and sulfonamide therapy, but finally did disappear after daily bladder irrigations and prostatic massages regularly twice a week. The prostatic secretion at first was full of pus cells. After removal of the ureteral catheter he had gross hematuria that lasted 8 days. Gross hematuria recurred January 7, February 11, and March 6, 1946. Each time it lasted 2 to 3 days but only once was it associated with pain which was felt in the right lower quadrant. Phenolsulphonphthalein injected intravenously on February 19 revealed an excretion of 50 per cent in the first half hour and 20 per cent in the second half hour. Cystoscopic examination on March 1, 1946, showed the bladder urine to contain a moderate number of pus cells. A 6 F. catheter passed up the left and then the right ureter without any obstruction. The left kidney urine was negative for pus cells; the right kidney urine showed 2 to 6 pus cells per high power field with an occasional clump. Culture from the right side was contaminated. On March 21, the urine showed only 10 to 12 pus cells per high power field in the centrifuged specimen. The blood pressure was 118/78 on March 28 and 120/80 on April 2, 1946 when he was discharged from the hospital. On March 29, 1946, the urine from each kidney was negative for pus cells and negative on routine culture. Phenolsulphonphthalein injected intravenously appeared in 3 minutes from the right kidney and 20 per cent of the dye was collected in the first 15 minutes. Because of unsatisfactory drainage through the catheter, the next specimen was collected transvesically 30 minutes after the appearance time and this showed 30 per cent of the dye. Both kidneys then excreted 50 per cent in 30 minutes. On January 2, 1946 (21 days postoperatively), intravenous urograms were taken (fig. 3, A). In 10 minutes after the injection of 20 cc of diodrast, a little dye was seen only in the upper calyces of the right kidney. In 20 minutes' time and with patient in the upright position the right kidney was even higher than the left. The pelvis showed good filling with excellent reduction in size. Both pelves were well outlined even after 3½ hours. On February 4, 1946 (54 days postoperatively), cystoscopic examination and retrograde pyelography on the right side were done. Urine from the left kidney was negative; on the right there were 1 to 4 pus cells per high power field in the centrifuged specimen. Without pain 30 cc water was injected and immediately 27 cc drawn back. Phenolsulphonphthalein injected intravenously appeared in 3 minutes from the right kidney and after 15 minutes only 10 per cent was collected. Further collection was not made because of unsatisfactory drainage through the catheter. Through a syringe and needle 25 cc of 20 per cent skiodan were injected without pain. The pelvis was further reduced in size but quite
710
BEN KLO'rZ
unexpectedly there was an extensive pyelotubular backflow throughout the kidney (fig. 3, B). The catheter was immediately withdrawn and the upright film showed a disappearance of the back.flow (fig. 3, C). There was complete emptying of the pelvis and calyces in a film taken 35 minutes in the upright position. Some dye was present after 10 minutes. Final x-rays were made March 1, 1946 or 79 days after operation. Retrograde pyelography after the injection of 20 cc of contrast medium under similar circumstances again revealed an extensive pyelotubular back.flow with a complete absence of pain. The right pelvis now measured 1 cm. across.
A
Fm. 3. A, January 2, 1946. Intravenous urogram, upright, 20 minutes after injection B, February 4, 1946. Retrograde pyelogram, supine, shows extensive pyelotubular back flow; pelvis even smaller. C, February 4, 1946. Shows high suspension of right kidney and almost complete disappearance of backftow.
In order to be sure to reduce the size of the pelvis adequately, some urologists (Mciver; Sargent; Walters) advocate the resection of as much of the redundancy as possible. This was not attempted here. Though the follow-up was short, the findings revealed that the requirements for an ideal repair had been met, namely, the elimination of pain, hydronephrosis, ptosis and infection, with the preservation of good renal function. DISCUSSION
The subject of backflow associated with the production of hydronephrosis has interested some investigators for some time (Bird and Moise; Fuchs;' Hepler; Hinman and Lee-Brown; Morison). Hepler (1937) and Morison (1929) in their studies on rabbits, carefully eliminated the factor of overdistention and showed conclusively that absorption is pyelotubular. In the present case retrograde pyelograms both before and after operation were made under identical circumstances but without overdistention as indicated by the absence of pain. To explain the preoperative absence of the back.flow one might hypothecate that
MODIFIED PYELOPLASTY FOR HYDRONEPHROSIS
711
as a result of the chronic obstruction, peritubular and intratubular swelling developed along with dilatation of the tubules. However, with the release of the obstruction and the resultant appearance of improved renal circulation (Hepler), the swelling subsided and the dilated tubules became demonstrable. CONCLUSIONS
A modified method to close the renal pelvis after its partial resection is presented. The procedure is applicable to some cases of hydronephrosis due to extrinsic obstructions at the ureteropelvic junction. The results obtained in this single case fulfilled the requirements for an ideal repair. Support is given to the view that in hydronephrotic atrophy resulting from ureteral obstruction absorption in the human is also pyelotubular. 817 St. Paul St., Baltimore, JVId. REFERENCES BELL, E.T.: Renal Diseases. Philadelphia: Lea & Febiger, 5th ed., 1946. BIRD, 0. E. AND MorsE, T. S.: Pyelovenous backflow. J. A. M.A., 86: 663-666, 1926. DAVIS, D. M.: Ureteral obstruction: Recent advances in its embryology, nosology and surgery. Brit. J. Urol., 19: 71-82, 1947. DEMING, 0. L.: Ureteropelvic obstruction due to extrinsic and intrinsic lesions of the ureter as a clinical entity and its treatment. J. Urol., 50: 420-431, 1943. DODSON, A. I.: Urological Surgery. St. Louis: 0. V. Mosby Co., 1944. FucHs, F.: Pyelovcnous backflowin the human kidney. J. Urol., 23: 181-216, 1930. Translated from the German by Dr. Frank Hinman, San Francisco. GrnsoN, T. E.: Classification of plastic repair of ureteropelvic obstructions. Surg. Gynec. & Obst., 80: 485-496, 1945. HENLINE, R. B. AND MENNING, J. H.: The management of hydronephrosis due to ureteropelvic obstruction. Preliminary report. J. Urol., 50: 1-24, 1943. HEPLER, A. B.: Intrarenal changes in hydronephrosis. J. Urol., 38: 593-604, 1937. HINMAN, F.: Hydronephrosis. In: Practice of Surgery. Hagerstown, Md.: W. F. Prior Co., Inc., vol. viii, chapt. 8, p. 1, 1944. HINMAN, F. AND LEE-BROWN, R. K.: Pyelovcnous backflow: Its relation to pelvic reabsorption, to hydroncphrosis and to accidents of pyelography. J. A. M.A., 82: 607-613, 1924. HuNNER, G. L.: Conservative renal surgery associated with ureteral stricture work. J. Urol., 9: 97-149, 1923. LuBASH, S. AND MADRID, A.: Ureteropyeloneostomy for hydronephrosis. J. U rol., 38: 634-642, 1937. l\foivER, R. B.: Plastic surgery of the renal pelvis. J. Urol., 42: 1069-1087, 1939. MooRE, T. D.: Lato results of surgmy in hydronephrosis. South. Med. J., 35: 425-433, 1942, MoRISON, D. lVL: Routes of absorption in hydroncphrosis; experimentation with dyes in the totally obstructed ureter. Brit. J. Urol., 1: 30-45, 1929. MUNGER, A. D.: A plea for a more conservative attitude in renal surgery. J. A. M.A., 132: 675-679, 1946. QUINBY, W.: Factors influencing the operative procedure in hydronephrosis. J. Urol., 38: 673-679, 1937. SARGENT, J. 0.: Conservative surgery in hydronephrosis. J. Urol., 38: 680-687, 1937. WALTERS, W.: Resection of the renal pelvis for hydronephrosis: Its complications and results. Surg. Gynec. & Obst., 51: 711-716, 1930. WALTERS, W., CABOT, H. AND PRIESTLEY, J. H.: Operative results in noncalculous hydronephrosis: Results in 71 plastic operations. J. Urol., 38: 688-691, 1937.
Vol. 60, No. 5, November 1948 Printed in U.S.A.
A MODIFIED PYELOPLASTY FOR THE CORRECTION OF HYDRONEPHROSIS DUE TO EXTRINSIC OBSTRUCTIONS AT THE URETEROPELVIC JUNCTION A
CASE REPORT
BEN KLOTZ
According to Hinman the subject of hydronephrosis is of greatest importance to the practicing clinician and surgeon because it is one of the commonest characteristics of disease of the genito-urinary system. From a study of 33,360 necropsies, Bell concluded that hydronephrosis is the most common form of renal disease. Not only because of its common occurrence but also because it is frequently found to exist bilaterally (Munger; Sargent) the choice of radical (nephrectomy) or conservative treatment becomes very often an important matter. The development of the surgical treatment of these obstructions at first followed the principles set forth by the general surgeons in their treatment of obstructions at the gastroduodenal junction. It was to be expected that urological surgeons would develop operative procedures of their own to correct obstructions at the ureteropelvic junction. It would be repetitious to list these operative procedures here for they have ceen repeatedly mentioned and classified by others (Dodson; Gibson; Lubash; Moore). Twenty-five years ago Runner stated: "In dealing with a mechanism as delicately balanced as is the ureteropelvic junction, and particularly when that mechanism has been badly disarranged by disease, one hesitates to lay down hard and fast rules. Each case differs from the preceding one in the problems presented and the surgeon should approach these problems with an open mind, ready to adopt the course that seems best fitted for the individual case." These sound remarks from a master surgeon are true even today. The procedure of choice for the individual surgeon still must depend upon his own inclination, belief, judgment, experience and resourcefulness (Davis; Deming; Henline and Menning; Quinby; Sargent; Walters, Cabot and Priestley). The modification herein described adopts, first, the principle of partial resection of the redundant pelvis; and secondly, the principle of preservation of the ureteropelvic junction. It was applied to a case in which the pelvis sagged medially and below the extrinsically obstructed, normally placed, ureteropelvic junction. CASE REPORT
L. H., a male aged 23, was admitted to the U. S. Naval Hospital, San Francisco, November 4, 1945, complaining of pain in the right flank, nausea and vomiting of several hours' duration. He stated that he had had three similar attacks since 1942. He had never passed any stones or blood. The physical examination in general was not significant. The right kidney was lower than normal but not tender. The blood pressure was 132/82. The urine showed 2 706
MODIFIED PYELOPLASTY FOR HYDRONEPHROSIS
707
plus albumin, a rare pus cell and 1-2 red blood cells per high power field. A preoperative phenolsulphonphthalein test was not recorded. Intravenous urograms in the upright position (25 minutes after injection) showed renal ptosis with angulation at the ureteropelvic junction on the right side. Both ureters, left pelvis and calyces were normal. The right pelvis and calyces were markedly dilated (fig. 1, A). Retrograde pyelography was done December 8, 1945. Thirty-five cubic centimeters of rather clear urine were aspirated from the right kidney. When centrifuged this showed several pus cells per high power field. While supine about the same amount of 20 per cent Skiodan was injected' through a Luer syringe and needle (fig. 1, B). The
Fm. 1. A, November 13, 1945. Intravenous pyelogram, upright, 25 minutes after injection. B, December 8, 1945. Retrograde pyelogram, supine, after the injection of 30 cc. Note absence of backflow. C, December 8, 1945. Retention film after being upright for 10 minutes.
ureteral catheter was withdrawn, the patient was immediately placed in the upright position, and 10 minutes later a film (fig. 1, C) revealed findings similar to those in fig. 1, A. He had no pain whatsoever during or any time after the injection. On December 12, 1945, under spinal anesthesia, the right kidney was exposed through a lumbar incision. After severing a large vein which obstructed the ureteropelvic junction, the kidney was easily delivered. The ureteropelvic junction, the adjacent ureter and pelvis were surrounded by old, dense adhesions several millimeters thick. Free of adhesions, the ureteropelvic junction was wide and not thickened. The striking thing was the way the aberrant vein had caused the pelvis to sag medial to and belovv the ureteropelvic junction (fig. 2, a).
708
BEN KLOTZ
A long Kelly clamp was placed somewhat obliquely across the medial border of the pelvis in such a manner as to include the border of the portion that sagged below the ureteropelvic junction. A knife was passed along the under side of the clamp. The remaining pelvis was still larger than normal and its lowermost portion still sagged below the ureteropelvic junction. This junction showed no intrinsic narrowing because the closed end of a Kelly clamp passed through it easily (fig. 2, b). The opened pelvis was next partially closed from above downward with a continuous suture. This suture ended at a point where repeated trial approximations of the lower portion achieved the elimination of the sag (fig. 2, c). At the proper level the sagging portion of the pelvis was anchored with one mattress suture that started and ended on either side of the completed vertical suture line. Now the sag was eliminated and the ureter came off at a normal angle. But this left an opening almost horizontal to the above vertical
;f
~~-
'i
Fm. 2. Scheme: a, Operative findings and line of incision. b, Redundant pelvis resected. c, d, e, Method of closure. f, Method of drainage preferred.
line. The puckered ends of this transverse opening were leveled off with scissors and closure was completed with interrupted sutures (fig. 2, d, e). Chromic 00 catgut was used on the pelvis and none passed through the mucosa. Through a small opening left in the very uppermost end of the vertical suture line, a No. 7 whistle-tip ureteral catheter was passed into the pelvis and about 10 cm. down the ureter (fig. 2, f). Finally, a vertical pyelotomy almost 2 cm. long was made on the anterior surface about 1 cm. away from both the vertical and transverse suture lines. No catheter or tube was placed in this pyelotomy and no nephrotomy was made. The kidney was suspended high by means of a purse-string suture of No. 1 plain catgut taken through Gerota's capsule and anchored posteriorly below the twelfth rib in the region of the costovertebral ligament. Two cigarette drains were placed within Gerota's capsule down to the renal pelvis The wound was then closed in layers with No. 1 chromic catgut. The patient voided well during the first 24 hours and the urinary drainage through the wound was moderately profuse during this period. By the end of
MODIFIED PYELOPLASTY FOR HYDRONEPHROSIS
709
24 hours the temperature rose to 103 F. It gradually returned to normal by December 17. On this date one cigarette drain was removed. For the next 3 days the highest temperature was 100 F. On December 20 the urinary drainage from the wound was more profuse and for the first time he complained of pain. Upon removal of the remaining drain and the catheter from the ureter, his pain ceased dramatically. From then on there was no more urinary drainage. Numerous pus cells and red cells were found in the urine after December 24. The pyuria did not improve with penicillin and sulfonamide therapy, but finally did disappear after daily bladder irrigations and prostatic massages regularly twice a week. The prostatic secretion at first was full of pus cells. After removal of the ureteral catheter he had gross hematuria that lasted 8 days. Gross hematuria recurred January 7, February 11, and March 6, 1946. Each time it lasted 2 to 3 days but only once was it associated with pain which was felt in the right lower quadrant. Phenolsulphonphthalein injected intravenously on February 19 revealed an excretion of 50 per cent in the first half hour and 20 per cent in the second half hour. Cystoscopic examination on March 1, 1946, showed the bladder urine to contain a moderate number of pus cells. A 6 F. catheter passed up the left and then the right ureter without any obstruction. The left kidney urine was negative for pus cells; the right kidney urine showed 2 to 6 pus cells per high power field with an occasional clump. Culture from the right side was contaminated. On March 21, the urine showed only 10 to 12 pus cells per high power field in the centrifuged specimen. The blood pressure was 118/78 on March 28 and 120/80 on April 2, 1946 when he was discharged from the hospital. On March 29, 1946, the urine from each kidney was negative for pus cells and negative on routine culture. Phenolsulphonphthalein injected intravenously appeared in 3 minutes from the right kidney and 20 per cent of the dye was collected in the first 15 minutes. Because of unsatisfactory drainage through the catheter, the next specimen was collected transvesically 30 minutes after the appearance time and this showed 30 per cent of the dye. Both kidneys then excreted 50 per cent in 30 minutes. On January 2, 1946 (21 days postoperatively), intravenous urograms were taken (fig. 3, A). In 10 minutes after the injection of 20 cc of diodrast, a little dye was seen only in the upper calyces of the right kidney. In 20 minutes' time and with patient in the upright position the right kidney was even higher than the left. The pelvis showed good filling with excellent reduction in size. Both pelves were well outlined even after 3½ hours. On February 4, 1946 (54 days postoperatively), cystoscopic examination and retrograde pyelography on the right side were done. Urine from the left kidney was negative; on the right there were 1 to 4 pus cells per high power field in the centrifuged specimen. Without pain 30 cc water was injected and immediately 27 cc drawn back. Phenolsulphonphthalein injected intravenously appeared in 3 minutes from the right kidney and after 15 minutes only 10 per cent was collected. Further collection was not made because of unsatisfactory drainage through the catheter. Through a syringe and needle 25 cc of 20 per cent skiodan were injected without pain. The pelvis was further reduced in size but quite
710
BEN KLO'rZ
unexpectedly there was an extensive pyelotubular backflow throughout the kidney (fig. 3, B). The catheter was immediately withdrawn and the upright film showed a disappearance of the back.flow (fig. 3, C). There was complete emptying of the pelvis and calyces in a film taken 35 minutes in the upright position. Some dye was present after 10 minutes. Final x-rays were made March 1, 1946 or 79 days after operation. Retrograde pyelography after the injection of 20 cc of contrast medium under similar circumstances again revealed an extensive pyelotubular back.flow with a complete absence of pain. The right pelvis now measured 1 cm. across.
A
Fm. 3. A, January 2, 1946. Intravenous urogram, upright, 20 minutes after injection B, February 4, 1946. Retrograde pyelogram, supine, shows extensive pyelotubular back flow; pelvis even smaller. C, February 4, 1946. Shows high suspension of right kidney and almost complete disappearance of backftow.
In order to be sure to reduce the size of the pelvis adequately, some urologists (Mciver; Sargent; Walters) advocate the resection of as much of the redundancy as possible. This was not attempted here. Though the follow-up was short, the findings revealed that the requirements for an ideal repair had been met, namely, the elimination of pain, hydronephrosis, ptosis and infection, with the preservation of good renal function. DISCUSSION
The subject of backflow associated with the production of hydronephrosis has interested some investigators for some time (Bird and Moise; Fuchs;' Hepler; Hinman and Lee-Brown; Morison). Hepler (1937) and Morison (1929) in their studies on rabbits, carefully eliminated the factor of overdistention and showed conclusively that absorption is pyelotubular. In the present case retrograde pyelograms both before and after operation were made under identical circumstances but without overdistention as indicated by the absence of pain. To explain the preoperative absence of the back.flow one might hypothecate that
MODIFIED PYELOPLASTY FOR HYDRONEPHROSIS
711
as a result of the chronic obstruction, peritubular and intratubular swelling developed along with dilatation of the tubules. However, with the release of the obstruction and the resultant appearance of improved renal circulation (Hepler), the swelling subsided and the dilated tubules became demonstrable. CONCLUSIONS
A modified method to close the renal pelvis after its partial resection is presented. The procedure is applicable to some cases of hydronephrosis due to extrinsic obstructions at the ureteropelvic junction. The results obtained in this single case fulfilled the requirements for an ideal repair. Support is given to the view that in hydronephrotic atrophy resulting from ureteral obstruction absorption in the human is also pyelotubular. 817 St. Paul St., Baltimore, JVId. REFERENCES BELL, E.T.: Renal Diseases. Philadelphia: Lea & Febiger, 5th ed., 1946. BIRD, 0. E. AND MorsE, T. S.: Pyelovenous backflow. J. A. M.A., 86: 663-666, 1926. DAVIS, D. M.: Ureteral obstruction: Recent advances in its embryology, nosology and surgery. Brit. J. Urol., 19: 71-82, 1947. DEMING, 0. L.: Ureteropelvic obstruction due to extrinsic and intrinsic lesions of the ureter as a clinical entity and its treatment. J. Urol., 50: 420-431, 1943. DODSON, A. I.: Urological Surgery. St. Louis: 0. V. Mosby Co., 1944. FucHs, F.: Pyelovcnous backflowin the human kidney. J. Urol., 23: 181-216, 1930. Translated from the German by Dr. Frank Hinman, San Francisco. GrnsoN, T. E.: Classification of plastic repair of ureteropelvic obstructions. Surg. Gynec. & Obst., 80: 485-496, 1945. HENLINE, R. B. AND MENNING, J. H.: The management of hydronephrosis due to ureteropelvic obstruction. Preliminary report. J. Urol., 50: 1-24, 1943. HEPLER, A. B.: Intrarenal changes in hydronephrosis. J. Urol., 38: 593-604, 1937. HINMAN, F.: Hydronephrosis. In: Practice of Surgery. Hagerstown, Md.: W. F. Prior Co., Inc., vol. viii, chapt. 8, p. 1, 1944. HINMAN, F. AND LEE-BROWN, R. K.: Pyelovcnous backflow: Its relation to pelvic reabsorption, to hydroncphrosis and to accidents of pyelography. J. A. M.A., 82: 607-613, 1924. HuNNER, G. L.: Conservative renal surgery associated with ureteral stricture work. J. Urol., 9: 97-149, 1923. LuBASH, S. AND MADRID, A.: Ureteropyeloneostomy for hydronephrosis. J. U rol., 38: 634-642, 1937. l\foivER, R. B.: Plastic surgery of the renal pelvis. J. Urol., 42: 1069-1087, 1939. MooRE, T. D.: Lato results of surgmy in hydronephrosis. South. Med. J., 35: 425-433, 1942, MoRISON, D. lVL: Routes of absorption in hydroncphrosis; experimentation with dyes in the totally obstructed ureter. Brit. J. Urol., 1: 30-45, 1929. MUNGER, A. D.: A plea for a more conservative attitude in renal surgery. J. A. M.A., 132: 675-679, 1946. QUINBY, W.: Factors influencing the operative procedure in hydronephrosis. J. Urol., 38: 673-679, 1937. SARGENT, J. 0.: Conservative surgery in hydronephrosis. J. Urol., 38: 680-687, 1937. WALTERS, W.: Resection of the renal pelvis for hydronephrosis: Its complications and results. Surg. Gynec. & Obst., 51: 711-716, 1930. WALTERS, W., CABOT, H. AND PRIESTLEY, J. H.: Operative results in noncalculous hydronephrosis: Results in 71 plastic operations. J. Urol., 38: 688-691, 1937.