A New Plastic Operation for Stricture at the Uretero-Pelvic Junction: Report of 20 Operations1

A NEW PLASTIC OPERATION FOR STRICTURE AT THE URETERO-PELVIC JUNCTION REPORT OF

20

OPERATIONS 1

FREDERIC E. B. FOLEY INTRODUCTION

Obstruction at the uretero-pelvic junction 1s the sole cause of pure hydronephrosis. The hydrostatic effect of such obstruction is felt entirely above this point and produces so-called mechanical dilatation of the pelvis and calyces. In very early stages of the process there is no significant parenchymal injury, excretion is merely blocked and relief of the obstruction will be followed promptly by practically full recovery of function. If the obstruction is not relieved permanent anatomic change occurs in the renal parenchyma in the form of hydronephrotic atrophy. If neglected sufficiently long total destruction of renal parenchyma results, no degree of functional recovery is possible and nephrectomy is required. These facts emphasize the importance of early diagnosis and prompt relief of the offending obstruction. Indiscriminate nephrectomy for hydronephrosis is not to be countenanced. Better understanding of the pathologic process, accurate diagnosis and perfection of surgical technique have made possible conservative treatment and saving the kidney in all cases of hydronephrosis due to uretero-pelvic junction obstruction except those accompanied by suppuration affecting the parenchyma or parenchymal atrophy so advanced that no substantial degree of functional recovery is possible. The amount of actual function saved by a conservative procedure for relief of uretero-pelvic junction obstruction may be insignificant from the standpoint of the total renal function required, this being contributed almost entirely by the opposite normal kidney. From the standpoint of potential function, however, this salvaged parenchyma is of great importance, for it is capable of remarkable compensatory hypertrophy and hyperplasia with proportionate functional work. A kidney thus conserved may be capable of sustaining life in case of later total impairment or loss of the opposite kidney. Accordingly the potential function of the salvaged kidney has the same importance that attaches to the func1 Read before the American Urological Association meeting, Minneapolis, June 28-,July 1, 1937. 643

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FREDERIC E. B. FOLEY

tion of any kidney the object of surgical attack. By this token nephrectomy is contra-indicated in most cases of hydronephrosis just as well as it is contra-indicated in the numerous conditions for which conservative kidney operations are regularly employed as matters of course. These considerations have dictated present day conservatism in the surgical treatment of hydronephrosis. Obstruction at the uretero-pelvic junction causing hydronephrosis occurs in various forms. Some of these are purely mechanical and positional mal-relationships and may be said to be extrinsic. Belonging to the group of "extrinsic uretero-pelvic junction obstructions" are: lodgement of a calculus, high insertion of the ureter with valve effect, constriction by anomalous vessels, horizontal axial rotation of the kidney and nephroptosis. For the most part surgical relief of such obstruction is a comparatively simple technical problem, has given good results and has encouraged conservatism. In other cases obstruction is due to alteration in structure of the uretero-pelvic junction in the form of narrowing amounting to stricture and may be said to be intrinsic. "Intrinsic uretero-pelvic junction obstruction" may occur as a congenital mal-formation due simply to smallness of lumen without pathologic tissue change or as an acquired condition usually the result of inflammatory infiltration. From personal observation I am tempted to believe there is a third process of stricture formation in which the original cause of obstruction is extrinsic, as in anomalous vessel obstruction, and that the kinking and pressure incident to this result in pressure atrophy amounting to true intrinsic stricture. As contrasted with the extrinsic uretero-pelvic junction obstructions, those belonging to this group and caused by "stricture" present a much more difficult and intricate surgical problem. Relief of such obstruction by transurethral dilatation by ureteral bougies usually is not successful and almost regularly some form of plastic operation is required. The technical difficulty of plastic operations, the increased risk imposed by the time required for their performance, complications attending them and a high percentage of poor results has discouraged conservatism in this group of cases. The determining factors in favor of conservatism by plastic operation rather than nephrectomy are: 1. Ability to relieve obstruction. 2. Presence of potential function capable of sustaining life. 3. Non-prohibitive risk attaching to the operation. 4. Absence of the opposite kidney or severe impairment of its function.

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The matter to be presented in this paper deals only with hydronephrosis caused by stricture at the uretero-pelvic junction, its surgical treatment by a new method of plastic operation which I devised 14 years ago and the results obtained in 20 such operations in 19 different cases. In addition to these cases I have observed a number of cases of my associates-Dr. Donald Creevey of the University Hospital staff and my former associate, Dr. Philip Donohue-and have had access to the records and radiographs in them. Except for a single failure, finally requiring secondary nephrectomy, the results in these cases have been similar to my own. Accordingly a really substantial number of cases of the operation have been observed and only one secondary nephrectomy has been required. However, only my own 20 operations in 19 cases and the results secured in them are the basis of this report. This communication, containing the first formal description of the operation I have devised, has been withheld until this time to the end of having it contain a report of "eventual end results" by which the value of the procedure may be appraised. This has not been a feature of most previous reports bearing on other plastic operations for uretero-pelvic junction stricture. Mere description of a new procedure for this purpose unaccompanied by report of what it accomplishes as to: (1) symptomatic relief, attested by follow-up reports, (2) anatomic improvement, shown by check-up pyelograms and (3) functional improvement, demonstrated by test, is a contribution of questionable value and may be very misleading. EVOLUTION OF PELVIO-URETEROPLASTIES

Various procedures for relief of uretero-pelvic junction stricture have been described. All of these including my own, to be described here, are adoptions from general surgery of certain plastic principles. Their applications in the field of urology are not contributions of anything fundamentally new but represent a gradual evolution. End to side anastomosis of viscera had been employed in various ways before application of the principle in "uretero-pyeloneostomy" by Kiister in 1891 (fig. 1). The plastic principle of transverse suture of a longitudinal incision as applied to the pylorus in the Heineke-Mikulicz operation was adopted for use at the uretero-pelvic junction by Fenger in 1892 (fig. 2). The principle of continuous side to side union was used in plastic procedures on the skin before its application as a pyloroplasty by Finney. From this its use as a pelvio-ureteroplasty was only a natural step (fig. 3).

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FREDERIC E. B. FOLEY

The operation to be described here is a combination of well recognized plastic principles including the so-called "Y plasty." The principle of the simple Y plasty differs from the Heineke-Mikulicz principle only in detail: that is to say, one end of the longitudinal incision is split but essentially it consists of transverse suture of a longitudinal incision (fig. 4).

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4 FIG. 1. Reimplantation of ureter into pelvis-"uretero-pyeloneostomy"-by Kuster in 1891 was an adoption from general surgery. FIG. 2. The plastic principle of transverse suture of a longitudinal incision as applied to the pylorus in the Heineke-Mikulicz operation was adopted from general surgery for use at the uretero-pelvic junction by Fenger in 1892. FIG. 3. The plastic principle of the Finney pyloroplasty was adopted from general surgery for use at the uretero-pelvic junction. FIG. 4. The principle of the simple Y plasty differs from the Heineke-Mikulicz principle only in detail: one end of the longitudinal incision is split but essentially it consists of transverse suture of a longitudinal incision. 3

Durante applied this simple form of Y plasty to relief of pyloric stenosis before its application to the uretero-pelvic junction by Schwyzer in 1916 (fig. 5). Judging from published reports and from personal comment of individual experience by colleagues, the results secured with these several

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procedures have not been all that is to be desired. The percentage of poor symptomatic and functional results and complete failures requiring secondary nephrectomies has been too great to regard the achievement as satisfactory. Moreover there are not available reports concerning sympt-cmatic relief, functbnal change and anatomic condition based on follow-up informatbn, tests of function and check-up pyelo-ureterograms sufficiently long after operation from which to make an appraisal. As already indicated the present report has been deliberately withheld until this time that it might be free of this shortcoming. From the technical standpoint all these procedures have one or more than one of the following faults: 1. Undesirable puckering or folding at the suture line. 2. Persistence of high insertion of the ureter. 3. Absence of gradual funneling of the pelvis into the ureter. The last is common to all of them save Schwyzer's Y plasty (fig. 6). Conversely absence of puckering, correction of the high insertbn and gradual funneling all accomplished by one procedure would appear most desirable. The new operation to be described here accomplishes this. In the Durante plastic as applied to the uretero-pelvic junction by Schwyzer (fig. 6) the Y incision was placed in any convenient position, the stem of the Y in the ureter extending through the junction and diverging as two limbs in the pelvis but all of the incisbn in the same plane. The apex of the V shaped flap was slid downward and approximated into the lower end of the incision in the ureter, a turn or fold occurring in the edges of each limb of the Y. Although this method did not correct the usually present high insertion of the ureter, and required the undesirable sliding of tissues in one plane with the puckering incident to it, still it appeared to be a distinct advantage over the simple longitudinal incision and transverse suture of the Fenger operation in that the folding and puckering of tissues was well up in the pelvis above the junction. Moreover it produced some degree of gradual funneling. As shown in figure 7, the Finney operation was a logical evolution from the Fenger operation. In the latter the incision is made in one plane with distortion of the incision in this same plane for suture, whereas in the Finney operation the incision is made in two planes for approximation and suture without distortion. The Foley Y plasty differs from the Schwyzer operation in an analogous way (fig. 8). In the Schwyzer operation, incision is made in

648

FREDERIC E. B. FOLEY

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Fm. 5. The principle of the simple Y plasty as applied to the pylorus by Durante was adopted for use at the uretero-pelvic junction by Schwyzer in 1923. FIG. 6. In the Durante type of simple Y plasty as applied to the uretero-pelvic junction by Schwyzer the Y incision was placed in any convenient position, the stem of the Y in the ureter extending through the junction and diverging as two limbs in the pelvis but all of the incision in one plane. The V-shaped flap was slid downward and approximated into the lower end of the ureteral incision a tum or fold occurring in the edges of each limb of theY. FIG. 7. Evolution of the Finney type pelvio-ureteroplasty from the Fenger operation. In the Fenger operation, incision is made in one plane and is distorted for approximation and suture in the same plane. In the Finney type of plasty the incision is made in two planes with direct opposition of the two planes for suture without distortion. Fm. 8. Evolution of the "Foley Y plasty" from the Durante-Schwyzer operation. In the latter incision is made in one plane and is distorted for approximation and suture in the same plane. In the Foley operation incision is made in two planes with direct opposition of the two planes for suture without distortion (see figure 9).

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649

one plane with distortion of the incision in this same plane for suture, whereas in the Foley operation the incision is made in two planes with direct apposition of the two planes for approximation and suture without distortion. Correction of the usually present high insertion of the ureter should be considered an important detail in any plastic operation for ureteropelvic junction stricture. Failure to correct this abnormal relationship leaves a segment of ureter below the junction lying in contact with the pelvis so that the ureter lies between the pelvis on its lateral side and surrounding structures on its medial side. A one-way membrane valve effect is thus produced similar to the uretero-vesical valve (fig. 9). l ·)

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FIG. 9. Pelvio-ureteroplasty with failure to correct "high insertion of the ureter" leaves a "one-way membrane valve" similar to the uretero-vesical valve. Under certain conditions of distention, pressure and relationships, passage of urine from the pelvis will be prevented in the same way that regurgitation of urine from the bladder into the ureter is prevented.

Under certain conditions of distention, pressure and relationship passage of urine from the pelvis will be prevented in the same way that regurgitation of urine from bladder into ureter is prevented. THE FOLEY Y-PLASTY

The new operation is illustrated in the masterful drawings of William P. Didusch shown in figures 10, 11, 12 and 13. A large incision with very adequate exposure and complete freeing of the kidney are essential (fig. 10). It is folly to undertake a procedure technically so exacting under the handicap of insufficient room. By

650

FREDERIC E. B. FOLEY

careful examination the exact anatomic relations present and responsible for obstruction are determined. Particular attention is paid to the vascular arrangement and discovery of anomalous vessels playing a part

FIG. 10. Foley Y plasty for uretero-pelvic junction stricture

in the obstruction. If such vessels are found they are held out of obstructing contact with the ureter while pressure on the pelvis determines its freedom of evacuation and the presence or absence of intrinsic obstruction.

STRICTURE AT URETERO-PELVIC JUNCTION

651

A relatively high insertion of ureter is usually present so that the lateral wall of the ureter is opposite to or in contact with the medial wall of the pelvis. Almost regularly connective tissue or fibrous tissue J Anterior 0urr ace \ l or left kidney

2

FIG. 11. Foley Y plasty for uretero-pelvic junction stricture

adhesions are present between the pelvis and the segment of ureter in contact with it. Adhesions between pelvis and ureter are completely severed thus accurately exposing the uretero-pelvic junction (fig. 11). The latter is THE JOURNAL OF UROLOGY, VOL.

38,

NO.

6

652

FREDERIC E. B. FOLEY

carefully examined by inspection and palpation and if necessary by instrumental exploration through a small pyelotomy opening. By these means the presence or absence of "stricture" and the need for plastic operation are determined.

Y5haped flap ot pelvic wall turned down.. FIG. 12. Foley Y plasty for uretero-pelvic junction stricture

The kidney and ureter are held in position to give facility in accurately placing the Y incision in the pelvis and ureter (fig. 12). The stem of the Y is placed in the lateral wall of the ureter and thus will face the

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653

pelvis when normal position is restored. The incision is carried through the uretero-pelvic junction and downward in the medial wall of the pelvis an appropriate distance below the uretero-pelvic junction. From

FrG. 13. Foley Y plasty for uretero-pelvic junction stricture

this point the incision continues as two diverging limbs in the lower medial wall of the pelvis in the form of an inverted V. The incision in the ureter should equal in length the incision in the pelvis plus the length of the V shaped flap. The triangular opening in the pelvis and

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FREDERIC E. B. FOLEY

triangular shaped flap of pelvic wall when turned down face directly the incision in the ureter. The apex of the flap approximates directly into lower angle of the ureteral incision (fig. 13). By closely spaced interrupted sutures of 0000 chromic gut embracing only the muscularis with careful avoidance of the mucosa the edges of the ureteral incision are approximated directly to the edges of the triangular defect in the pelvis, the tip of the flap fitting neatly into the lower end of the ureteral incision. Upon completion of the suture a soft rubber catheter of size FlO or F12 is introduced through a small stab opening on the posterior surface of the pelvis and is directed into the ureter a distance of 6 or 8 cm. A number of small fenestrations are cut in the portion of catheter lying within the pelvis. The catheter serves to splint the sutured segment and provides for drainage of urine from the pelvis. It is left in place for about one week. A second catheter extending only into the pelvis is introduced for use in through and through irrigation. Upon removal of the splinting catheter this second catheter may be used to test the freedom with which a colored solution such as mercurochrome will pass downward into the bladder. TECHNICAL CONSIDERATIONS CONCERNING PYELO-URETEROGRAMS AND FUNCTIONAL TESTS

Before turning to report of the cases in which the operation has been performed it is wished to touch on three points which are of very considerable importance in determining anatomic and functional conditions present with hydronephrosis and in appraising what has been accomplished by operation. 1. The "apparent" uretero-pelvic junction seen in the usual anteroposterior pyelo-ureterogram may not be the true uretero-pelvic junction at all (fig. 14). The oblique position of the kidney in the renal fossa makes an anteroposterior radiograph of the patient, an oblique radiograph of the kidney. In consequence of this the shadow of a dilated pelvis may overlie the true uretero-pelvic junction. The shadow of the ureter below the junction joining the pelvic shadow will then appear as the urcter::i-pelvic junction. To overcome this the patient should be so rotated that the plane of the kidney is parallel to the plane of the x-ray film. In this way the bulging pelvis is thrown away from the junction and the latter is photographed in profile (fig. 24). 2. In the presence of a dilated pelvis the appearance time of indigo-

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carmine and color concentration of the ureteral jet are not reliable criteria of renal function. A prenchyma of really good function may secrete its urine into a greatly dilated pelvis with such dilution of the dye as to cause marked delay in appearance time and lack of concentration in the jet. The same applies to pthalein tests with ureter catheters. In this case however, aspiration of pelvic contents at the end of the collection period and addition of the aspirated urine to what has dripped from the catheter gives an accurate indication. These considerations apply equally to the original diagnostic study and to check-up examinations to determine the result of operation .

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FIG. 14. Difference between "antero-posterior" and "rotated position" pyelograms. The oblique position of the kidney in the renal fossa is such that with the patient in the A-P position, the shadow of a dilated pelvis may overlie the shadow of the true uretero-pelvic junction and ureter. The shadow of the ureter joining the pelvic shadow will then appear as the junction and may be misleading. In the "rotated position" the plane of the kidney is parallel to the film, the pelvic and ureteral shadows are separated and the junction is photographed in profile (see figures 19A and 24A).

3. Similar considerations apply in the interpretation of pyelo-ureterograms and require that the hydrodynamics of renal, pelvic and ureteral physiology be taken into account in making them. The method of making the pyelo-ureterogram should be designed to show the anatomic relations under which the kidney is functioning at the time of examination, not the extent to which the pelvis can be artificially distended. The usual method of filling the pelvis to the point of pain production does not accomplish this for the resulting pyelogram gives an outline of "potential pelvic capacity" which may be an entirely different thing from the "pelvic content" actually present without instrumentation. Under existing functioning conditions and without the artificial factor of instrumentation "pelvic content" will equal "potential pelvic capac-

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FREDERIC E. B. FOLEY

ity" only in the presence of obstruction. A pelvis which has been dilated and has lost its tone as a result of obstruction will contain under abnormally high tension a "pelvic content" equal to its "potential pelvic capacity" only so long as obstruction persists. Adequate relief of obstruction, by operation or otherwise, permits the same pelvis to contain under diminished tension a much smaller "pelvic content" than it had in the presence of obstruction. Accordingly to show the true relations under which the kidney is functioning at the time of examination and in order to demonstrate what effect obstruction, if present, is having, the pyelo-ureterogram should be made by aspirating the pelvis through a catheter and refilling with a volume of contrast medium equal to the aspirated fluid. The contrast medium is best injected from the lower end of the ureter upward by means of a bulb catheter wedged into the orifice. In this way good filling at the site of stricture or plastic rer:air is usually obtained and the resulting pyelogram outlines relations under which the kidney is actually functioning. Pyeloureterograms made by intravenous injection and excretion of the contrast substance accomplish the same purpose as the method of retrograde pyelography outlined above but unfortunately they usually fail to give outlines sufficiently definite to show the position, caliber and relations of the uretero-pelvic junction, how these have been altered by obstruction, or to show what has been accomplished by operation. The above three points have been dwelt upon at this length because of their important bearing on the interpretation of the findings of examination in both the pre-operative diagnostic study and in appraising what has been accomplished by operation. REPORT OF CASES

The operation described has been employed 20 times in 19 different cases and makes one of the largest series of plastic operations for hydronephrosis to be reported.

FIG. 15. Case 1. A, Bilateral pyelogram before operation. Right hydronephrosis grade 2, left hydronephrosis grade 4 (side of operation). B, Left pyelogram 13 years after operation. Dilatation less, wide funnel shaped uretero-pelvic junction at most dependent part of pelvis, function greatly improved.

Case report. Female aged 47. May 1923. Left flank pain, hematuria, general ill feeling. Operation for left hydronephrosis (Fenger) 1921 elsewhere gave a poor result and no relief. Division of anomalous vessel and nephropexy 1922 for right hydronephrosis gave satisfactory result. Left kidney enlarged and tender. Right hydronephrosis grade 2, left hydronephrosis grade 4. Operation: Tensely distended left pelvis, adhesions about ureter, high insertion and stricture of junction. Lysis, Y plasty, plication of pelvis. Complete relief of pain, improved function, marked improvement in general physical condition.

FrG. 16. Case 2. A, Right pyelogram before operation. Hydronephrosis grade 3, deformity of uretero-pelvic junction, normal ureter. B, right pyelogram 1 month after operation. Dilatation much improved, wide and dependent uretero-pelvic junction, slightly deformed by tissue infiltration of repair process. C, Right pyelogram ten years after operation. The improvement demonstrated in previous film 1 month after operation is shmYn to be permanent.

Case report. Male, aged 12 years. March 1926. Right flank and upper quadrant pain several months' duration. Nausea and vomiting. Tenderness right flank. Right hydronephrosis grade 3. Operation: Tensely distended right pelvis, adhesions about ureter_, stricture of junction. Lysis, division of obliterated anomalous vessel, Y plasty. Complete relief of pain, improved function. 657

FIG. 17. Case 3. A, Bilateral pyelograms before operation. Left hydronephrosis grade 1, right hydronephrosis grade 3 (side of operation), uretero-pelvic junction concealed by shadow of pelvis, no medium escapes into ureter. B, Right pyelogram 1 year 4 months after operation. Dilatation much improved, wide and dependent uretero-pelvic junction, slightly deformed by tissue infiltration of repair process. Case report. Male aged 51. October 1927. Abdominal pain not well localized, bladder irritation, tenderness right flank. Right hydronephrosis grade 3 (side of operation), left hydronephrosis grade 1. Operation: Distended right pelvis, fibrous band and adhesions, high insertion and stricture of junction. Lysis, Y plasty. Complete relief of pain, improved function. Patient died 4 years after operation of other cause.

FIG. 18. Case 4. A, Left pyelogram before operation. Hydronephrosis grade 1, ureteropelvic junction deformed but dependent. Relations not well suited to Y plasty. Inflammatory change grade 1 affecting ureter. B, Left pyelogram 5 years after operation. Dilatation of pelvis diminished, uretero-pelvic junction not of normal appearance but somewhat improved. Case report. Female aged 42. July 1929. Intermittent left flank pain 15 years' duration, severe colics, nocturia. Tenderness left flank. Pyuria, left hydronephrosis grade 1, inflammatory changes ureter grade 1. Operation: Left uretero-pelvic adhesions, greatly thickened musculature of uretero-pelvic junction with filiform stricture of lumen. Lysis, Y plasty. Pain and pyuria continued for some time; finally complete relief of pain and disappearance of pyuria accompanied by marked improvement in general phys~cal condition.

658

FIG. 19. Case 5. A, Left pyelogram before operation. Hydronephrosis grade 3-4, uretero-pelvic junction concealed by shadow of pelvis (very high insertion found at operation). See figure 14. B, Left pyelogram 8 months after operation. Dilatation much improved, very broad and completely dependent junction. C, Excretion urogram (12 min. film) 6 years after operation. (Uretero-pelvic junction poorly defined in original film, shaded for reproduction.) Good function of left kidney, well marked further improvement of dilatation, uretero-pelvic junction poorly outlined but of broad funnel shape. Case report. Male aged 40. May 1930. Hematuria and left flank pain following injury; pain persisted. Left hydronephrosis grade 3-4. Operation: Tensely bulging left pelvis, old adhesions (not attributable to recent injury), high insertion and stricture of ureter. Lysis, resection of pelvis, Y plasty, nephropexy. Complete relief of pain, improved function.

FIG. 20. Cas.e 6. A, Bilateral pyelogram before operation. Left hydronephrosis grade 2, very high insertion of ureter (side of operation). B, Left pyelogram 7 years after operation. Dilatation improved, wide funnel shaped and dependent uretero-pelvic junction. Case report. Female, aged 35. September 1930. Pain left flank and left side of abdomen 2 years' duration, severe colics, bladder irritation. Tenderness left side of abdomen. Left hydronephrosis. Operation: Distended left pelvis, anomalous vessel, high insertion, stricture of junction. Division anomalous vessel, Y plasty. Complete relief of pain and bladder irritation, improved function. 659

FIG. 21. Case 7. A, Bilateral pyelogram before operation. Right hydronephrosis grade 2, left hydronephrosis grade 3, deformity of uretero-pelvic junction, high insertion of ureter (side of operation). B, Left pyelogram 24 days after operation and 1 hour after postoperative death of patient ("post mortem pyelogram"). Dilatation much improved, ureteropelvic junction of funnel shape and perfectly dependent. Immediately below junction outline of ureter is greatly narrowed. At autopsy this segment of ureter was found to have a normally large lumen its walls merely being compressed by the surrounding tissue infiltration of the repair process. Remaining portions of ureter dilated (post mortem a tony?). Case report. Female aged SO. November 1930. Right flank pain, discovery of mass in abdomen, bladder irritation, loss of weight, chills, fever, malaise. Tenderness both flanks, both kidneys palpable. Nitrogen retention, right hydronephrosis grade 2, left hydronephrosis grade 3 (side of operation). Operation: Loosely attached left kidney, tense pelvis, very high insertion and stricture of junction. Y plasty, nephropexy. Fulminating type of impetigo contagiosa developed following operation, postoperative death 24th day. Autopsy showed multiple extensive lesions of impetigo contagiosa, bronchial pneumonia. Fat and other tissues in left renal fossa infiltrated incident to repair process. Edges of plastic incision in pelvis and ureter perfectly approximated but surrounded by infiltrated fat.

FIG. 22. Case 8. A, (Patient aged 7 years.) Left pyelogram per nephrostomy tube (a first film showed none of the contrast medium passing into the ureter, a ureteral catheter was passed) and ureterogram per ureteral catheter before Y plasty. Hydronephrosis grade 3, deformity of uretero-pelvic junction, high insertion. B, Left pyelogram (patient 14 years of age) 7 years after operation. (Compare size of skeleton with that shown in A.) In proportion to increased stature, dilatation of pelvis is markedly less with wide funnel shaped uretero-pelvic junction completely dependent.

660

Case report. Female aged 7 years. November 1930. Left flank pain, chills, fever. bladder irritation, 3 months duration, general ill feeling, retarded development. Temperature 103°, tenderness left flank, left kidney palpable. Pyuria, right hydronephrosis grade 1, left hydronephrosis grade 3 (side of operation). Preliminary left nephrostomy for drainage. Operation: Left uretero-pelvic adhesions, anomalous vessels, high insertion and stricture of junction. Lysis, division of anomalous vessels, Y plasty. Complete relief of pain, improved function, marked improvement of general physical condition.

FIG. 23. Case 9. A, Left pyelogram before operation. Hydronephrosis grade 3, ureteropelvic junction not outlined being obscured by dilated pelvis, no medium escapes into ureter. B, Left pyclogram 3 years after operation (35 cc. urine aspirated by catheter, same quantitJ· of medium injected on withdrawal of catheter). Dilatation less, uretero-pelvic junction not well outlined but completely dependent. Case report. Male aged 19. June 1933. Left flank pain 2 years duration, dull aching character. Temperature elevation, tenderness left flank, left kidney palpable. Pyuri.a, left hydronephrosis grade 3. Operation: Tense left pelvis, anomalous vessel, high insertion, thickening of musculature of junction, stricture of junction. Division of vessel, Y plasty. Complete relief of pain, improved function, disappearance of pyuria.

Case 10. Pyelograms not shown. Case report. Female aged 27. Septem'::ler 1930. Intermittent pain right upper quadrant and flank. Tenderness right upper quadrant and flank, right kidney palpable. Right hydronephrosis grade 3. Operation: Tensely distended right pelvis, anomalous vessels, high insertion, stricture of junction. Division of vessels, Y plasty, nephropexy. Virulent wound infection, hyperpyrexia with temperature 108 degrees first post-operative day. Right nephrectomy second post-operative day as extremis measure. Death third post-operative day. (Radiographs and pyelograms have bee:1 lost.)

661

FIG. 24. Case 11. A, Right pyelogram before operation per pyelostomy tube (a preliminary film showed no passage of the contrast medium into ureter, ureter catheter inserted) and ureterogram per ureteral catheter. Hydronephrosis grade 3, stricture of uretero-pelvic junction, high insertion of ureter, inflammatory changes grade 1 affecting ureter, nephrostomy tube in left kidney. (Compare this pyelogram with figure 14 and note that with slight rotation of the patient the shadow of the dilated pelvis would have been superimposed upon the shadow of the uretero-pelvic junction, and the latter would have appeared to enter the most dependent part of the pelvis and would have appeared as of wide funnel shape. Very frequently antero-posterior exposure fails to show the junction in profile in this way. Rotation of the patient toward the side opposite to the pyelogram best assures the "profile" outline.) B, Right pyelogram 3 years after Y plastic operation. Dilatation slightly less, uretero-pelvic junction of wide funnel shape and completely dependent. Case report. Female, aged 25. March 1934. Right flank and abdominal pain, general ill feeling, loss of weight, weakness. Diagnosis: Bilateral hydronephrosis grade 3, right renal lithiasis. Previous operations (all performed by writer): March 7, 1931, right pelviolithotomy and nephrostomy for drainage; March 28, 1931, left pyelostomy for drainage; July 7, 1931, left ureterolysis and insertion of dilating and splinting catheter. Nephrostomy drainage. Eventual good result. Preoperative diagnosis: Right hydronephrosis grade 3, bilateral nephrostomy for drainage, pyuria. Operation: Right uretero-pelvic adhesions, high insertion and stricture of junction. Lysis, Y plasty. Complete relief of pain, improved function, disappearance of infection, marked improvement in general physical condition.

662

FIG. 25. Case 12. A, Left pyelogram before operation. Hydronephrosis grade 3, uretero-pelvic junction not shown being obscured by dilated pelvis. B, Left pyelogram 1 month after operation. Dilatation improved, urete.ro-pelvic junction well outlined, funnelshaped and dependent. Case report. Male aged 43. March 1935. Intermittent left flank pain, severe colics, nocturia. Tenderness left flank, left kidney palpable. Left hydronephrosis grade 3. Operation: Distended left pelvis, anomalous vessels, high insertion and stricture of junction. Division of anomalous vessels, Y plasty, nephropexy. Complete relief of pain. Death 4 months later of other cause.

FrG. 26. Case 13. A, Right pyelogram before operation made 5 minutes after removal of catheter and demonstrating well marked retention. Large percentage of medium in pelvis. Hydronephrosis grade 2, high insertion of ureter. At operation the insertion was found to be considerably higher than its appearance in this film. B, Right pyelogram 2 years after operation. Dilatation improved, uretero-pelvic junction completely dependent but of good form. 663

Case report. Female aged 21. March 1935. Right flank and right abdominal pain severe colics, bladder irritation. Tenderness right flank. Pyuria, right hydronephrosis grade 2, inflammatory changes right ureter grade 1. Operation: Right uretero-pelvic adhesions, anomalous vessel, high insertion and stricture of junction. Lysis, division of vessels, Y plasty, requiring resection of parenchyma and modified form of operation. (See figure 27 .) Complete relief of pain, improved function, disappearance of pyuria.

Ant(n0r

Pcuter(or

FIG. 27. Relations found at operation in case 13 and modified form of operation employed. A heavy prominent lower lip of the renal sinus reached up almost to the junction obscuring the pelvis helow it. A section of parenchyma was excised to expose the surface of pelvis and inferior calyx required for the Y incision.

FIG. 28. Case 14. A, Bilateral pyelogram before operation. Right pelvis inadequately filled, left hydronephrosis grade 3 (inferior calyx poorly filled, outlined in ink), left ureteropelvic junction partially obscured by dilated pelvis, high insertion of ureter. B, Left pyelogram 2 years after operation. Dilatation little if at all improved (filled under greater tension than A). Uretero-pelvic junction obscured by inferior calyx (another check-up pyelogram 6 months after operation made at a slightly different angle outlined the junction in profile and showed it to be of wide funnel outline and completely dependent). Pregnancy 6 months uneventful. Case report. Female aged 23. July 1935. Generalized abdominal pain, attacks of severe pain in right lower quadrant. The Y plasty was performed on the left side because of the more advanced left hydronephrosis. Appendectomy without relief. No tenderness either flank, neither kidney palpable. Right hydronephrosis grade 1, left hydronephrosis grade 3 (side of operation). Operation: Distended left pelvis, high insertion and stricture of junction. Y plasty, nephropexy. Generalized abdominal pain not completely relieved but improved, function left kidney improved, right sided pain continues. Exploration right kidney contemplated. 664

FIG. 29. Case 15. A, Excretion urogram before operations, 1 hour film. Impaired function both kidneys, high percentage retention of medium both pelves, right hydronephrosis grade 2, left hydronephrosis grade 3, neither uretero-pelvic junction outlined. B, Left pyelogram 5 months after operation on left side. Dilatation less, ·wide funnel shaped, completely dependent junction. C, Right pyelogram 1 year 4 months after operation on right side. (Filled under greater tension than excretion urogram A.) Dilatation somewhat less, broad funnel shaped, completely dependent junction.

Case report. Female aged 13. Pain both flanks 1 year duration, severe right colics, nausea, vomiting, bladder irritation, pallor, undernourishment, general ill feeling, lethargy. Pallor, undernourished, underdeveloped, tenderness both flanks. Pyuria, right hydronephrosis grade 2, left hydronephrosis grade 3. Operation: Left side August 1935; right side November 1935. Same findings, same procedure each side: adhesions, anomalous vessel, high insertion and stricture of junction. Y plasty, nephroxy. Division of anomalous vessels on left side only. Complete relief of pain, disappearance of pyuria, improved function, marked improvement general physical condition, normal progress of development.

Frc. 30. Case 16. A, Left pyelogram before operation. Hydronephrosis grade 1, ureteropelvic junction obscured by dilated saccule of pelvis immediately above and medial to it. B, Left pyelogram 4 months after operation. Dilatation slightly less, deformity of uretero-pelvic junction corrected, complete relief of pain. Case report. Female aged 21. September 1935. Periodic left flank pain 5 years duration. Severe colics, nausea, vomiting. Fever, tenderness left flank. Left hydronephrosis grade L Operation: Left uretero-pelvic adhesions, unusual insertion of ureter and de-formity of pelvis at junction, stricture of junction. Y plasty, modified form (see figure 31) nephropexy. Complete relief of pain.

665

3

4

FIG. 31. Relations found at operation in case 16 and modified form of operation employed. A saccular dilatation of pelvis immediately above junction bulged downward medial to ureter with ureter entering lateral aspect of pelvis above saccule. There was filiform stricture of junction. Adhesions between saccule and ureter were separated and plastic repair was effected as indicated by placing stem of Y incision in medial instead of lateral wall of ureter thus facing saccular dilatation of pelvis. The divergent branches of Y incision were turned downward in lateral wall of saccular dilatation. In the conventional form of operation the stem of the Y is in the lateral wall of the ureter and the divergent limbs are in the medial wall of the pelvis.

FIG. 32. Case 17. A, Left pyelogram before operation. Hydronephrosis grade 4, upper ureter and inferior border of pelvis deformed (anomalous vessels), uretero-pelvic junction obscured by dilated pelvis (very high insertion found at operation). B, Excretion urogram 1 year after operation, 50 minute film. Impaired but improved function, dilatation much improved, uretero-pelvic junction not outlined but almost certainly dependent and unobstructed. Case report. Male aged 26. June 1935. Pain left flank, intermittent 20 years duration, nausea, vomiting, chills, fever, discovery of left upper abdominal mass. Fever, tenderness left flank, left kidney enlarged and tender. Pyuria, left hydronephrosis grade 4. Operation: Left uretero-pelvic adhesions, anomalous vessel, high insertion and stricture of junction. Division of anomalous vessel, Y plasty. Complete relief of pain, improved function.

666

FIG. 33. Case 18. A, Bilateral pyelogram before operation. Left hydronephrosis grade 1, left uretero-pelvic junction deformed, right hydronephrosis grade 2 (side of operation), unusual deformity of right pelvis: a fusiform dilatation above the junction lies folded against lower portion of pelvis which extends downward to be continuous with the inferior calyx. The junction of the ureter with the fusiform dilatation of pelvis is deformed. B. Bilateral pyelogram 9 months after right Y plasty. Dilatation of right pelvis less, broad uretero-pelvic junction completely dependent.

Case report. Female aged 24. August 1936. Right flank and abdominal pain intermittent, 4 years duration, recent severe right sided colics. Tenderness right flank. Left hydronephrosis grade 1, right hydronephrosis grade 2 (side of operation). Operation: Tense bulging right pelvis, anomalous vessel, stricture of junction ·with unusual deformity of pelvis above junction. Division of vessel, Y plasty, modified form requiring resection of parenchyma (see fig. 34). Complete relief of pain, improved function.

ANTERIOR ANTERIOR SURFACE

SURFACE

DISTORTION OF VESSEL

HYDRONEPHROSIS ANOMALOUS VESSEL

VIEWED f"ROM BEHIND

OBSTRUCTION

VESSEL

DIVIDED

DISTORTION CORRECTED U-P-.1 STRICTURE

A.NTERIOR SURFACE

ANTERIOR SURFACE

FIG. 34. Relations found at operation in case 18 and modified form of operation employed. The uretero-pelvic junction and fusiform dilatation of pelvis bulged forward ove~ an anomalous vessel ,,-ith the ureter and junction drawn up against the posterior surface ol pelvis. After division of the vessel, stricture of the junction was found. A portion of parenchyma was excised to expose the inferior calyx and portion of pelvis lateral to fusiform dilatation. The stem of the Y incision was made unusually long extending through the fusi-form dilatation into the pelvis lying lateral to it and down into the calyx. The approximation and suture \\'ere made as indicated. 667 'l'HE JOURNAL OF UROLOGY, VOL.

38,

NO.

6

668

FREDERIC E. B. FOLEY

FrG. 35. Case 19. A, Left pyelogram before operation. Pelvis inadequately filled. Hydronephrosis grade 1, uretero-pelvic junction not well visualized. B, Left pyelogram 9 months after operation. Pelvis ,Yell filled. Dilatation more pronounced, uretero-pelvic junction dependent. Case report. Male aged 25. August 1936. Left flank pain, intermittent 1 year duration, severe colics, nausea, vomiting. Tenderness left flank. Left hydronephrosis grade 2. Operation: Distended left pelvis, anomalous vessel, high insertion and stricture of junction. Division of anomalous vessel, Y plasty. Complete relief of pain except for slight discomfort on one occasion. ANALYSIS OF RESULTS

Data concerning the 20 operations have been tabulated in table 1 and form the basis for appraising the value of the operation. In practically all cases check-up pyeloureterograms, functional tests and report as to relief of symptoms have been obtained at long intervals following operation. Without such data, communications and reports of cases bearing on this subject are of little or no value in appraising the methods employed. It will be noted (table 1) that in almost half the cases the interval of time from the date of operation to the present is 7 years or more and that 15 of the 19 patients are living at the present time. Report of symptomatic relief was obtained in all cases and in every case but 3 the report was obtained a year or more following operation. In 6 cases it was obtained 7 years or more after operation. In all but one

TABLE I SYMPTOMATIC RESULT GRADE

YEARS

CASE

HYDRO-

NUMBER

NEPHROSIS

SINCE OPERATION

Years after operation - - - - ~ - ~--- - - -

4 3 3 1 3

1

2 3 4

5

2 3

6

7 8 9

10 11

12

13 14

15 fL

\R

16

17 18 19

3 3 3 3 3 2 3 3 2 1 4 2 2

14

14

11

11

10

4 8

8

7 7 7 7

7

ANATOMIC AND FUNCTIONAL RESULT BY CYSTOSCOPY AND PYELOGRAM OR EXCRETION UROGRAM

Years after operation ----

13 10 1¼ 6 6

7

Excellent Excellent

3 3 1

3

2 2 2 2 1

3

1

1 3

3

4

4 -----

Excellent Excellent Excellent Good Excellent Excellent Good Excellent Excellent Good

7

7 3

3 1

1:t

2 2 l

'

Function

Appearance . at ureteropelv1c junction

I Disappearance

Improved Normal Normal Improved Improved Normal

1 mo.

4 4 3 2 2 2 2 2 2 1 1

I RESULT IN

Grade

Excellent Excellent Excellent Excellent Excellent Excellent

7

1

~

1l3

-, 1

1 1 3

4

·----------

Excellent Excellent Excellent Good Excellent Excellent Fair Improved Excellent Improved Fair Fair Improved Excellent Unaffected Excellent Improved Fair Improved Good Improved Excellent Improved Excellent Normal Excellent Improved ? Improved Excellent Unaffected I Fair

--~-

--

--

----- ----

-

---

-

----·

REMA"RKS

GENERAL

[fJ

of d·]at f 1 < a ion

Moderate Complete Complete Moderate Complete Moderate Moderate Moderate Slight

H

I

?" H

-----~

Excellent Excellent Excellent Good Excellent Excellent

(")

H

C1

?" M

Death 4 years other cause

C1

~

Post-operative death 28th day Good Good

I I I

Good Good Good Fair Good Good Good Good Good Fair

- - ------- - - - - - -

H

M ?" 0

>tj Post-operative death 4th day

Slight Slight Moderate None Moderate Slight Slight Moderate Moderate None

~

H

Death 4 months other cause

M

r

< H (") ,....,

zC1 (")

H

8

z

Unable to follow

--------~

°' °' \Q

670

FREDERIC E. B. FOLEY

case, that of a post-operative death, functional tests and check-up pyeloureterograms were made to show the condition after operation. In 14 of the cases these examinations were made a year or more following operation. In 6 cases the check-up examination was made 6 years or more after operation. It is evident therefore that the subjective result as reported by the patient and the objective result as determined by functional tests and pyeloureterograms represent eventual end results in the majority of cases. In the cases of short interval between operation and the check-up examination the anatomic result and improvement of function demonstrated cannot be regarded as definitely permanent. However, in a number of cases, repeated check-up examinations were made, the last ones at long intervals after operation. These cases tend to show that with this procedure a good anatomic result and functional improvement demonstrated soon after operation will further improve and will be permanent. That is to say, the widening of the uretero-pelvic junction accomplished by this operation does not appear to be followed by recontraction, recurrence of obstruction and starting anew the anatomic and functional impairment as has been found to be the case with some types of pelvioureteroplasty. Disappearance of pelvic dilatation has not been all that is to be desired in all cases though it has occurred in notable degree in most of them. Some degree of improvement of function occurred in all but 2 cases. In spite of the fact that anatomic restoration and functional recovery have not been complete the subjective relief was "excellent" or "good" in all cases. In all but case 9 and case 16 report as to the symptomatic result up to the time of preparing this report or up to the time of death is available, so that from the standpoint of subjective relief the follow-up information is complete to date except in these 2 cases and in all it is either excellent or good. In case 9, the last follow-up information was qbtained a year ago, 3 years after operation and in case 16 it was obtained a year and 9 months ago, 4 months after operation. Two patients (case 3 and case 12) have died of other cause at long intervals following operation. In addition there were 2 cases of postoperative death (case 7 and case 10). In the first instance, case 7, death occurred on the 24th day due to a fulminating type of impetigo other cases of which were present in the hospital at the same time. In this case a post mortem pyeloureterogram (fig. 21 B) and post mortem

671

STRICTURE AT URETERO-PELVIC JUNCTION

examination showed the pelvic dilatation greatly diminished and an anatomic condition promising a good result. In the second instance, case 10, death occurred on the 4th day due to a virulent wound infection accompanied by a positive blood culture. In this case the kidney was removed as an extremis and heroic measure the third day following operation. Subtracting the 2 cases of death from other cause and the 2 cases of post-operative death, there are 15 surviving patients in whom the operation has been performed 16 times. Table 2 shows the results obtained in 10 cases of operation performed less than 7 years ago. These cannot be considered definite end results but as early results they are favorable. TABLE

2.-0perations less than 7 years ago; 9 si,rviving patients (10 operations)

Excellent ....................... . Good ........................... . Fair... . ...................................... . Poor. ............................................ .

TABLE

SYMPTOMATIC RESULT

FUNCTIONAL AND ANATOMIC RESULT

7

2

3

4

0 0

4 0

3.-0perations 7 or more years ago; 6 sitrviving patients

Excellent. ................. . Good ...................................... . Fair ............. . Poor .................. .

SYMPTOMATIC RESULT

FUNCTIONAL AND ANATOMIC RESULT

6 0 0

3 3 0

0

0

Table 3 shows the results obtained in 6 cases of operation performed more than 7 years ago. These are definite end results and are even more favorable than those obtained in the group of more recent operation. The data gathered from these cases in regard to subjective relief, improvement of function, disappearance of infection, anatomic restoration and the result in general indicate that the criteria of a good result, in order of importance, are: 1. Relief of pain and other symptoms. 2. Improvement of function. 3. Disappearance of infection. 4. Disappearance of dilatation.

672

FREDERIC E. B. FOLEY

Disappearance of dilatation and anatomic improvement as demonstrated in the pyelouretrogram are desirable but not essential. Delayed secondary nephrectomy has not been required in any case and contrasts sharply with reports concerning conservative treatment of hydronephrosis by other forms of plastic operation for relief of stricture at the uretero-pelvic junction. The complete absence of secondary nephrectomy, the good anatomic and functional results and the excellent subjective relief all indicate that the procedure is considerably more successful than other procedures for similar purpose which have been described. It is felt that the usual form of "Report of Cases" contains an abundance of unessential detail that imposes on the reader an unnecessary task and serves no useful purpose. Moved by this consideration the cases here reported conform with the writer's views as to what is appropriate to serve the intended purpose. SUMMARY AND CONCLUSIONS

The results of former plastic operations for uretero-pelvic junction stricture causing hydronephrosis have not been all that is to be desired. Anatomic and functional condition as disclosed by functional tests and pyelo-ureterograms at long intervals following operation as well as report concerning subjective relief are essential to accurate appraisal of surgical accomplishment. A new plastic operation for uretero-pelvic junction stricture is described. Nineteen cases in which the operation was performed 20 times are reported. The anatomic, functional and symptomatic results determined by pyelo-ureterograms, tests of function and follow-up information at long intervals after operation are submitted. The new operation appears to yield better results than those reported for other operations of similar purpose.

Lowry Bldg., St. Paul, Minn. REFERENCE ScHWYZER: Surgical Clinics of North America, 3: 1441-1448, 1923.