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A New Method of Removal of Calculi from the Male Urethra
THE JOURNAL OF UROLOGY
Vol. 60, No. 4, October 1948 Printed in U.S.A.
A NEW METHOD OF REMOVAL OF CALCULI FROM THE MALE URETHRA MARTIN J. LOEB From the private service of the Bronx Hospital, New York, N. Y.
A calculus in the bladder, if forced into the urethra, is accomplished by the centrifugal force of the urinary stream. How far the stone will be pushed forward depends upon the force of the urinary stream, the circumference of the urethra, its expansibility, the size of the stone, and obstacles in the path of its progress. The pressure in the bladder varies in the same individual as well as in different individuals under the same conditions and circumstances. The futility of estimating averages was well stated by Homer Smith who said: "The average of biological variation, the mean represents something that is nonexistent, a product of our imagination and the more carefully it is derived the more it is removed from reality. In that there is less probability of it being identified with one individual." The pressure in the bladder depends upon the hydraulic force of the measured urine in the bladder and the tonicity of its muscles. Allowing for variations one can state that about 300 cc of urine in the bladder plus the tonicity of its muscles will produce a pressure of 8 mm. of mercury or thereabouts. The urethra is usually collapsed and the surfaces meet but on distension the widest part of the urethra measures about 8 mm. It may be stretched from 30 to 45 mm. depending upon the variation of the calibre of the urethra in its various parts. The force of the stream ·will expand the urethra as it pushes the stone forward. The pressure of the stream is stronger at the internal urinary meatus. As the stream enters into the urethra its propulsive force is diminished because the elastic urethra in its expansion by the force of the urinary stream uses up part of that force. As the pressure diminishes, the urethra is less expanded and the pressure on the calculus is also diminished. A stricture in any part of the urethra, enlarged lateral lobes of the prostate impinging upon the posterior urethra, or an enlarged verumontanum will overcome the force of the urinary stream and prevent the expulsion of a calculus. A diverticulum in the urethra will imprison the stone. There are four points of normal narrowing in the urethra, one at the external meatus, the second at the penoscrotal junction, the third at the membranous urethra and the fourth at the internal sphincter. A stone may be impeded in its exit by any of these normal narrowings. Abnormal or normal impediments in the urethra will cut off the progress at the point of obstruction. During propulsion the stone may change its relation to the axis of the urethra which will impede its further progress; or a protruberance of the stone may penetrate the mucosa of the urethra where it will become fixed and resist its dislodgement by the pressure of the urinary stream. 640
REMOVAL OF CALCULI FROM MALE URETHRA
641
The conditions propitious for the expulsion of a stone from the urethra may be duplicated by hydraulic expansion of the urethra and manual pressure. The method is as follows: the urethra is compressed manually or mechanically in back of the stone. Pressure is applied by a clamp at the external meatus. Methycaine (2 per cent) in water or oil is injected into the urethra ·which will serve a, dual purpose; one, to anesthetize the urethra and, secondly, to expand the urethra between the two pressure points (fig. 1). As the urethra is expanded the stone can be moved by gentle manipulation since the urethra is subcutaneous
Fm. 1. Illustrating method described for removal of stones from male urethra. In this illustration stone is located in urethra below penoscrotal junction. Tourniquet applied around penis posterior to stone in order to compress urethra. Clamp is applied to penis posterior to corona. Methycaine (2 per cent) is injected and forced by bulb syringe through clamp into urethra until urethra is dilated and stone can be pushed and floated down by manual pressure behind stone. As soon as stone reaches external meatus, it may be removed with forceps. If stone is located behind penoscrotal junction an assistant compresses urethra behind stone manually since no tourniquet or clamp can be applied in that locality.
and the stone may be easily felt. Should the stone be embedded in front of the penoscrotal junction a tourniquet made from a small catheter may be used instead of manual compressiono A penile clamp may be applied instead of the tourniquet. If the stone is behind that point an assistant must use manual pressure to compress the urethra so that the fluid will remain within its lumen, As the stone is pushed forward and reaches the external meatus it may be removed from there with a forceps. I have employed this method of removal of calculi from the male urethra for the past 15 years quite successfully. It saves the patient and the surgeon a great deal of trouble since the entire process can be accomplished within a few minutes.
642
MARTIN J. LOEB CASE REPORT
L. F., No. 192124, was admitted to the Bronx Hospital June 22, 1947 because of a calculus in the lmver end of the right ureter and marked right hydronephrosis. The patient also suffered from a stricture of the urethra, secondary to a previous Neisserian infection. Dilatation of the urethra was done and gradually increased from No. 12 sound to No. 28 at which time it was possible to introduce a cystoscope into the bladder. By ureteral meatotomy and catheter manipulation in the ureter the calculus was brought down into the bladder. The dilatation and cystoscopy were done under local anesthesia and the procedure took quite some time. The patient became tired so I decided to send him home and remove the calculus from the bladder at a later date . :,-
"; __
_
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FIG. 2. Stone removed from urethra
On July 2, the patient came to my office and gave me the following history. During the night he experienced sudden severe pain in his urethra during urination. Subsequently he had difficulty in urination as well as dysuria. He was able to pass urine in a dribble. He felt a calculus in his urethra. I used the above-described method to remove the stone from his urethra. The entire procedure took about 10 minutes. Since the stone had a rough surface the impossibility of its motion in a narrow, collapsed urethra can be easily understood. The calculus measured 13 mm. in length and 7 mm. at its widest point. The surface was quite rough with many small protruberances dotting it (fig. 2). The patient passed this calculus into the urethra to the penoscrotal junction where it remained fixed for about eight to ten hours. SUMMARY
A new method to remove impacted calculi from the male urethra is described.
I have no experience in removing stones from diverticula of the urethra by this method. However, I believe, that the method may be tried with success.
1882 Grand Concourse, Bronx 57, N. Y. SMITH,
H. W.: Plato and Clementine.
REFERENCE Bull. New York Acad. Med., 23: 352-377, 1947.
Vol. 60, No. 4, October 1948 Printed in U.S.A.
A NEW METHOD OF REMOVAL OF CALCULI FROM THE MALE URETHRA MARTIN J. LOEB From the private service of the Bronx Hospital, New York, N. Y.
A calculus in the bladder, if forced into the urethra, is accomplished by the centrifugal force of the urinary stream. How far the stone will be pushed forward depends upon the force of the urinary stream, the circumference of the urethra, its expansibility, the size of the stone, and obstacles in the path of its progress. The pressure in the bladder varies in the same individual as well as in different individuals under the same conditions and circumstances. The futility of estimating averages was well stated by Homer Smith who said: "The average of biological variation, the mean represents something that is nonexistent, a product of our imagination and the more carefully it is derived the more it is removed from reality. In that there is less probability of it being identified with one individual." The pressure in the bladder depends upon the hydraulic force of the measured urine in the bladder and the tonicity of its muscles. Allowing for variations one can state that about 300 cc of urine in the bladder plus the tonicity of its muscles will produce a pressure of 8 mm. of mercury or thereabouts. The urethra is usually collapsed and the surfaces meet but on distension the widest part of the urethra measures about 8 mm. It may be stretched from 30 to 45 mm. depending upon the variation of the calibre of the urethra in its various parts. The force of the stream ·will expand the urethra as it pushes the stone forward. The pressure of the stream is stronger at the internal urinary meatus. As the stream enters into the urethra its propulsive force is diminished because the elastic urethra in its expansion by the force of the urinary stream uses up part of that force. As the pressure diminishes, the urethra is less expanded and the pressure on the calculus is also diminished. A stricture in any part of the urethra, enlarged lateral lobes of the prostate impinging upon the posterior urethra, or an enlarged verumontanum will overcome the force of the urinary stream and prevent the expulsion of a calculus. A diverticulum in the urethra will imprison the stone. There are four points of normal narrowing in the urethra, one at the external meatus, the second at the penoscrotal junction, the third at the membranous urethra and the fourth at the internal sphincter. A stone may be impeded in its exit by any of these normal narrowings. Abnormal or normal impediments in the urethra will cut off the progress at the point of obstruction. During propulsion the stone may change its relation to the axis of the urethra which will impede its further progress; or a protruberance of the stone may penetrate the mucosa of the urethra where it will become fixed and resist its dislodgement by the pressure of the urinary stream. 640
REMOVAL OF CALCULI FROM MALE URETHRA
641
The conditions propitious for the expulsion of a stone from the urethra may be duplicated by hydraulic expansion of the urethra and manual pressure. The method is as follows: the urethra is compressed manually or mechanically in back of the stone. Pressure is applied by a clamp at the external meatus. Methycaine (2 per cent) in water or oil is injected into the urethra ·which will serve a, dual purpose; one, to anesthetize the urethra and, secondly, to expand the urethra between the two pressure points (fig. 1). As the urethra is expanded the stone can be moved by gentle manipulation since the urethra is subcutaneous
Fm. 1. Illustrating method described for removal of stones from male urethra. In this illustration stone is located in urethra below penoscrotal junction. Tourniquet applied around penis posterior to stone in order to compress urethra. Clamp is applied to penis posterior to corona. Methycaine (2 per cent) is injected and forced by bulb syringe through clamp into urethra until urethra is dilated and stone can be pushed and floated down by manual pressure behind stone. As soon as stone reaches external meatus, it may be removed with forceps. If stone is located behind penoscrotal junction an assistant compresses urethra behind stone manually since no tourniquet or clamp can be applied in that locality.
and the stone may be easily felt. Should the stone be embedded in front of the penoscrotal junction a tourniquet made from a small catheter may be used instead of manual compressiono A penile clamp may be applied instead of the tourniquet. If the stone is behind that point an assistant must use manual pressure to compress the urethra so that the fluid will remain within its lumen, As the stone is pushed forward and reaches the external meatus it may be removed from there with a forceps. I have employed this method of removal of calculi from the male urethra for the past 15 years quite successfully. It saves the patient and the surgeon a great deal of trouble since the entire process can be accomplished within a few minutes.
642
MARTIN J. LOEB CASE REPORT
L. F., No. 192124, was admitted to the Bronx Hospital June 22, 1947 because of a calculus in the lmver end of the right ureter and marked right hydronephrosis. The patient also suffered from a stricture of the urethra, secondary to a previous Neisserian infection. Dilatation of the urethra was done and gradually increased from No. 12 sound to No. 28 at which time it was possible to introduce a cystoscope into the bladder. By ureteral meatotomy and catheter manipulation in the ureter the calculus was brought down into the bladder. The dilatation and cystoscopy were done under local anesthesia and the procedure took quite some time. The patient became tired so I decided to send him home and remove the calculus from the bladder at a later date . :,-
"; __
_
. . <>··· • ".··.'.' .f. .•· .• ·\;:~: .·•.· •· . . .;,:} ~
FIG. 2. Stone removed from urethra
On July 2, the patient came to my office and gave me the following history. During the night he experienced sudden severe pain in his urethra during urination. Subsequently he had difficulty in urination as well as dysuria. He was able to pass urine in a dribble. He felt a calculus in his urethra. I used the above-described method to remove the stone from his urethra. The entire procedure took about 10 minutes. Since the stone had a rough surface the impossibility of its motion in a narrow, collapsed urethra can be easily understood. The calculus measured 13 mm. in length and 7 mm. at its widest point. The surface was quite rough with many small protruberances dotting it (fig. 2). The patient passed this calculus into the urethra to the penoscrotal junction where it remained fixed for about eight to ten hours. SUMMARY
A new method to remove impacted calculi from the male urethra is described.
I have no experience in removing stones from diverticula of the urethra by this method. However, I believe, that the method may be tried with success.
1882 Grand Concourse, Bronx 57, N. Y. SMITH,
H. W.: Plato and Clementine.
REFERENCE Bull. New York Acad. Med., 23: 352-377, 1947.