Calculus of the upper urinary tract

CALCULUS OF THE UPPER URINARY TRACT* A. R. STEVENS, M.D., AND C. W. COLLINGS, NEW

YORK

E wish to present certain data concerning 70 patients with caIculus of the upper urinary tract, operated upon at BeIIevue HospitaI by the staff of the UroIogicaI Service; aIso to state brieffy our present attitude toward certain probIems encountered in this work.

W

RENAL

CALCULUS

There were 164 patients discharged from the hospita1 the past six years with the diagnosis of nephroIithiasis. Forty-eight of these were operated upon and form the basis of this review. Three were readmitted for operation on the opposite side. Our wards aIways contain a reIativeIy Iarge proportion of individuaIs of foreign birth, and it is therefore not surprising that I I nationaIities were represented in this group. About one-third were born in the United States and an equa1 number in ItaIy. As to the age incidence, our patients were about equaIIy divided beIow and above forty. Our youngest case was twenty, and the oIdest seventy-three. HospitaI ruIes prohibit the admission of children under fourteen years of age in the Urologica1 Service. Complaint: Th e most frequent compIaint was Ioin pain, noted in 80 per cent, while abdomina1 pain was recorded in 15 per cent of the cases, urinary frequency in 12 per cent and hematuria in IO per cent. Occasiona compIaints were anuria, foulsmeIIing urine, dysuria, Ioss of weight, weakness, nausea and vomiting, headache, testicular pain and muItipIe arthritis. Past Urinary HistoTy: Thirty per cent onIy had had previous uretera coIic; 7 per cent previous attacks of hematuria; IO per cent had passed a stone; nearly 15 per cent had had previous operation for caIcuIus; and 12 per cent (a11 with right renaI stone) had submitted to appen* Submitted

M.D.

dectomy, quite possibIy because of uretera pain. Examination: Tenderness in the kidney area posteriorIy was found in nearly 60 per cent of the cases. AbdominaI tenderness occurred in about 30 per cent. The renaI function on the diseased side in uniIatera1 stone cases as compared with the other kidney, was determined by the urea content of the urines, and the output of indigo carmine and phenoIsuIphonephthaIein. It was found that the function was decreased in 70 per cent of the kidneys harboring stones. CuriousIy in 3 instances the function as indicated by these tests was reaIIy increased. Infection of the urine obtained from the caIcuIus side was present in nearIy 85 per cent. The pyeIograms showed some diIatation of the peIvis or caIyces in g5 per cent but rareIy if ever the irreguIar outIine of kidney destruction. Of the biIatera1 stone cases, we caI1 particuIar attention to 3 patients, whose output of phthaIein in two hours before operation was surprisingIy Iarge, 65 per cent, 50 per cent and 50 per cent respectiveIy. In these patients, the compIaints demanding operation were renaI pain in aI1, chiIIs and fever in I, and hematuria in r. ILLUSTRATIVE CASE REPORTS For contrast, the foIlowing 2 interesting cases of biIatera1 caIcuIus disease are cited. CASE I. E. B., male, aged forty-eight, entered the hospita1 compIaining of pain in both flanks. He had had a pyelotomy for stone fifteen years earIier. He had been under the observation of one of us for five years, and had sought advice because of cIoudy urine. UreteraI catheterization had repeatedIy demonstrated infection of both kidneys, and the phthalein report was exceIIent, aIthough roentgenograms showed stones on both sides

for pubIication February 484

21. 1930.

NEW SBR~HS VOL. IX, No. 3

Stevens

and CoIIings-CaIcuIus

(See Fig. 3). But there were no symptoms and the genera1 heaIth was good over this period. FinaIIy chiIIs and fever developed,

FIG.

I.

CaIcuIus in renaI pelvis producing hydronephrosis. EIeven stones in gaIl hIadder.

with severe pain in both kidney regions. On admission to the hospital, the patient’s

FIG. 2. MultipIe catculi in one kidney. Kidneys show equal function and no inflection. Yet for thirty-seven years patient has had occasional hematuria, especialiy after exercise, without pain. Operation not advised, as condition good and patient comfortabIe.

phthaIein output in two hours was 65 per cent. The right kidney gave but a trace of urea, no

American journalof surgery 485

indigo carmine, but some pus and micrococci; the Ieft kidney gave 0.5 per cent urea, bIue coIor in eight minutes, pus and micrococci. Left pyeIotomy and nephrotomy were done for muItipIe caIcuIi (Fig. 4). PhthaIein output on discharge was 25 per cent. On readmission, four months later, it was 30 per cent. The right kidney gave no urea, no dye, but much pus and cocci; the Ieft kidney gave 0.3 per cent urea, paIe bIue coIor, cIumps of pus and some cocci. Right nephrectomy was performed for advanced caIcuIus pyonephrosis. Two weeks after operation, the phthaIein was 40 per cent in two hours. Patient continues in good heaIth to date, eight months after operation. CASE II. C. A., maIe, aged thirty-two, entered hospita1 complaining of pain in the Ieft Ioin, fou1 urine, headache and nausea. Non-protein nitrogen in the blood pIasma was 145 mg. per IOO c.c., and creatinine was 3.6. Cystoscopies showed thick ribbons of pus from both ureters; there was no phthaIein output in eighteen minutes, and no indigo carmine in twenty-five minutes from either side. Roentgenograms proved caIcuIi in both kidneys. The usual medica therapy was persisted in but avaiIed nothing; surgery in

FIG. 3. BiIateraI caIcuIi. MuItipIe stones removed from left kidney. Later right nephrectomy for caIcuIous pyonephrosis.

our opinion was contraindicated. The patient became graduaIIy worse, with vomiting and other evidences of toxemia and died on the seventeenth day. N.P.N. three days before

486

American Journal of Surgery

Stevens and CoIIings-CaIcuIus

death was 132, creatinine 4.0; one day before death, N.P.N. was 282 and creatinine was 4.7. Anesthesia:

In the earIier cases of the

FIG. 4. Stones removed from left kidney of case shown in Fig. 3.

group here reported, genera1 anesthesia was used. Having used spina anesthesia with increasing satisfaction in perinea1 and suprapubic work the past ten years, we were Ied to try it in kidney and uretera operations, as the technic had improved and the safeguards muItipIied. In 1928 spina anesthesia was used in I I kidney operations. Three of these, Iasting over one hour, required some genera1 anesthesia at the cIose. Contrary to the opinion expressed by some anesthetists, we find that patients under spina anesthesia take the added genera1 anesthesia with particuIar ease. SpinaI anesthesia gives marked muscuIar reIaxation during the operation, Ieads to Iess postoperative distention, Iess gastrointestina1 upset and fewer re-

SEPTEMBER, 1930

spiratory compIications. For routine work, we beIieve it to be the method of choice. However, it must be empIoyed onIy with a thorough knowIedge of the technic and dangers. The great risks are anesthesia of the meduIIary centers and rapid faI1 of bIood pressure. To combat the former, the spina puncture is done with the patient Iying on one side, and the head is kept Iower than the hips during and after operation. To combat the Iatter, we depend aImost soIeIy upon ephedrine. UniformIy a subcutaneous injection of 50 mg. is given at the time of the spina tap. An interne is detaiIed to watch the bIood pressure, and further injections of ephedrine, subcutaneous or even intravenous, are given as indicated. However, spina anesthesia is not for universa1 appIication. There are some emotiona and apprehensive patients who are constitutionaIIy unfitted for it. Operation: An obIique Ioin incision paraIIeI to the Costa1 margin and keeping above the tweIfth dorsa1 nerve, is aImost aIways empIoyed by us. In some cases, the stone is easiIy feIt in the peIvis or upper ureter, and readiIy removed without sheIIing the kidney from its fatty capsuIe. We beIieve this shouId be done when feasibIe. Otherwise the kidney is freeIy mobiIized and brought out of the wound if the Iength of the pedicIe permits. It seems universaIIy agreed that pyeIotomy is preferabIe to nephrotomy. When incision of the renaI cortex is necessary we prefer to extend the pyeIotomy wound into the kidney parenchyma upward or downward as the position of the stone indicates, carefuIIy avoiding visibIe vesseIs. Any bIeeding vessel may be carefuIIy cIamped and tied. Often such hemorrhage is quickIy and is preferabIy controIIed by pressure. These kidney incisions are cIosed by a few superficia1 mattress sutures pIaced in the capsuIe. We have, avoided deep through and through sutures as tending to cause pressure necrosis, at times additiona hemorrhage, and postoperative infection. This superficia1 suture

NEW SERIESVOL. IX. No. 3

Stevens

has compIeteIy

controIIed the bIeeding. When isoIated caIcuIi are present in caIices, it may be necessary to cut the convex

FIG. 5. Tuberculous calcification in lower kidney resembling renaI caIcuIus.

American journalof surgery 487

and CoIIings-CaIcuIus

calyx

of

surface of the kidney parenchyma. We prefer muItipIe smaI1 incisions to one Iarge one. After doing nephrotomy, we aIways incise the peIvis and Ieave it open for drainage. There were IO cases requiring nephrotomy in this group. None had subsequent hemorrhage nor any secondary operation. It has been a question with us for some time whether suture of ureterotomy or pyeIotomy wounds hastened the heaIing. Some of these cases without suture have never drained urine, and we are using sutures in decreasing numbers. At present only the Iarger incisions are sutured and they onIy partIy so. If there is no obstruction, Ieakage from a uretera incision wiI1 be IittIe; the norma peristaIsis carries urine toward the bIadder. If there is some permanent or even temporary obstruction, it is much better for the patient that an opening in the ureter be Ieft. Wounds: No cIean wounds in this series, that is, wounds Ieading to uninfected kidneys, became infected. AI1 wounds but 3 of 15 pyeIotomy cases with definite notes, heaIed flush with the skin within twenty days; 2 in twenty-five days. One

case Ieaked urine forty-two days; this heaIed onIy after severa indweIIing ureteral catheters had been used.

FIG. 6. Calcified Iymph node outside middIe calyx.

The nephrectomy wounds heaIed on an average of one week earIier than the pyeIotomy wounds. Of the whole series of kidney cases, 4 wounds had to be opened because of infection. Stay in Hospital: About 40 per cent of the patients Ieft the hospita1 fifteen to nineteen days after operation; 40. per cent in twenty to twenty-eight days; and 20 per cent remained in hospita1 over four weeks. Deaths: Of the 51 patients having renal caIcuIus who were operated upon, 8 died. BeIieving that our faiIures are of particuIar interest, we record a few facts concerning these 8 deaths. AI1 of them occurred within two weeks after operation; 2, within twenty-four hours. Perhaps it is onIy fair to state again that this series of operations for renaI caIcuIus with such a high mortaIity rate concerns only patients of a municipa1 hospita1. A Iarge percentage of these patients are admitted in very bad coridition, and circumstances frequentIy compe1 us to take grave risks (Note Cases III, VI, VIII-x foIIowing). CASE

III.

MaIe,

aged

sixty-three,

had

a

488

American Journal of Surgery

Stevens

and CoIIings-CaIcuIus

Iarge caIcuIus removed through a pyeIotomy incision. He was in a weakened condition with a poorIy functioning heart, but operation had to performed because of continued pain. Condition satisfactory immediateIy after operation, but patient became graduaIIy weaker and died of myocarditis two weeks after operation. CASE IV. MaIe, aged thirty-three, was operated upon for stones in the renaI peIvis. The pedicIe was accidentIy torn during the dissection, severe hemorrhage ensued necessitatPatient died in tweIve hours. ing nephrectomy. CASE v. MaIe, aged forty-seven, had a nephrotomy for caIcuIus. Previous cystoscopy showed no infection of either kidney. Condition satisfactory unti1 the thirteenth day when the patient suddenIy became cyanotic and died. The attending physician diagnosed cornary emboIism. No autopsy. CASE VI. MaIe, aged fifty-nine, had right nephrectomy for caIcuIus pyonephrosis. Genera1 condition poor before operation. N.P.N. was 60 and creatinine 2.5 four days before operation. PhthaIein tests 20 per cent in two hours one day before operation. Because of pain in the kidney region and infection, operation was imperative. Condition improved IittIe after nephrectomy. On the tenth postoperative day, there was a chiI1 with temperature IOI’F., and severe sharp pain in the right Iower quadrant. Patient died the next day; no autopsy. ProbabIe cause of death was thrombosis. CASE VII. MaIe, aged thirty-four, was admitted with biIatera1 renaI caIcuIi, a Iarge dentritic stone on the right side, and a Iarge calcuIus in the Ieft peIvis. On cystoscopy, the right ureter gave thick pus, no urea, no dye; the Ieft ureter, no pus, good urea, and phthaIein in seven minutes. Under spina anesthesia, the very adherent right kidney was removed. Temperature after operation registered from 101 to 104.6’~., the pulse was rapid and abdomen markedIy distended. Distention couId be reIieved onIy temporariIy, and patient died on fifth postoperative day. No autopsy. CASE VIII. 1Male, aged fifty-four, entered hospita1 with pain in right Ioin and hematuria. Roentgenograms showed stones in both kidneys. On cystoscopy, right ureter discharged thick pus, and Ieft ureter cIear urine; no

SEPTEmaer, ,930

indigo carmine came from either kidney in eIeven minutes. N.P.N. ten days before operation was 56; creatinine 3.0. N.P.N. five days before operation was IOO, creatinine 3.0. Perinephritis abscess became apparent and was drained; no further operation done. On second postoperative day, N.P.N. was 300, creatinine 4.3. Condition steadiIy grew worse, and patient died on seventh day after operation. No autopsy. CASE IX. MaIe, aged forty-three, was admitted with severe pain in the right Ioin, vomiting and headache. He had been operated upon for stones in the right kidney two years earIier, and had had a IithoIapaxy a year before that. N.P.N. a week after admission was 200, creatinine 2.6; twelve days Iater, N.P.N. was 30, and creatinine 2.2. No cystoscopy, the right kidney gave a faint trace of indigo carmine and 0.65 per cent urea; Ieft kidney, medium coIor and I. I per cent urea. There was some infection on both sides. Because of the poor condition, no operation was done unti1 six weeks after admission. However the pain continued and operation the right kidney was seemed imperative; removed under genera1 anesthesia. Operation was not unduIy proIonged, yet the patient went into shock on the tabIe and died the next morning. No autopsy. CASE x. Male, aged fifty-three, was admitted with a history of anuria for twenty hours. Was reIieved by indweIIing catheters for three days when he insisted on going home. He was abIe to urinate for four days, then deveIoped troubIe again and returned after three days of anuria. DoubIe indweIIing uretera catheters were introduced at once. The next day N.P.N. was 84 and creatinine 4.5. Five’days Iater, (the catheters having been withdrawn), the N.P.N. was 230; the catheters were reintroduced. SeveraI phthaIein tests done at various times gave zero output in two hours. Roentgenograms showed small shadows at the uretero-peIvic junctions on both sides. From time to time the uretera catheters were withdrawn; patient would become anuric and uremic, and catheters wouId be reinserted. FinaIIy on the twenty-fifth day after admission, N.P.N. was 56 and creatinine 3.2. Operation offered the onIy hope of permanent reIief, as otherwise better condition was dispaired of. Right pyeIotomy was finaIIy

New SERVESVOL.IX, No. 3

Stevens

and CoIIings-CaIcuIus

performed and stone removed. There was considerabIe infiItration of the perinephritic fat noted. Patient died three days later. Autopsy showed a smaI1 right kidney with caIcareous incrustations and perinephritis; thickened waII of the corresponding ureter, 2 cm. below the peIvis. The Ieft kidney was Iarge (25 cm. Iong) and had puruIent materia1 in the peIvis; at the uretero-peIvic junction there was a caIcific deposit obstructing the ureter. URETERAL

CALCULUS

There were 153 patients discharged from the hospital during the past six “uretera caIcuIus.” Of years, diagnosed these, 22 were operated upon by our staff. As with our patients having renaI caIcuIus, over haIf of this group of 22 uretera cases were born in this country or Italy. Considering their ages, g were in the fourth decade of Iife, 6 in the third, and 6 in the fifth decade, whiIe but one was over fifty. Complainl: Pain was the outstanding symptom; in 12, it was referred to the back; in the other 8, to various parts of the abdomen (I to the penis). Hematuria was compIained of but twice, anuria once and urinary frequency once. Fast History: Pain had occurred on the same side which was the seat of the present troubIe, in 5 instances, from onehaIf to eight years earIier; hematuria, once, two years before; stone passed from the same side, once, two and one haIf years before; ureterotomy, once, eight years before; appendectomy on side of present troubIe, once, eight years earIier. Present Illness: Eighteen cases had pain in the kidney region; 3 had uniIatera1 abdomina1 pain. Of these 21 patients, 8 had radiation of the pain to the groin or testicIe. Examination: There was costovertebra1 tenderness in 15 patients, and abdomina1 tenderness in but 3, whiIe 6 patients presented no tender area. As the genera1 phthaIein test was usuaIIy good before operation, there couId be no

American ~0urna1 of Surgery 489

appreciabIe improvement thereafter; no case showed a decrease of output after operation. The onIy interesting observation on bIood chemistry concerned a patient with biIatera1 ureterai caIcuIi, causing aImost compIete anuria. His N.P.N. jumped from 55, five days before operation, to 137 on the day of operation, creatinine going from 1.5 to 4.5. Four days after doubIe pyeIotomy both constituents were normaI. Catheters were made to pass the uretera stones in a11 cases but 4. The renaI function on the invoIved side was decreased in 14 of 15 cases where uretera specimens were obtained; one showed no decrease. The function on the invoIved side showed definite improvement in a11 of 5 cases tested after operation. There was demonstrated diIatation of the urinary tract above the stone in a11 of the 4 patients in whom cIear pyeIograms were obtained. Infection was present on the invoIved side in I I of the 15 cases. After operation, the infection was absent in 2 cases cystoscoped, decreased in I, and unchanged in I. The uninvoIved kidney was found infected twice and uninfected in 16 cases. Operation: Incisions naturaIIy varied with the Iocation of the stones. They were high, practicaIIy as for a kidney operation, and Iow (over peIvic ureter) in about equa1 numbers. The Iow incisions were usuaIIy obIique, foIIowing in genera1 that described by Gibson. In 4 instances the vertica1 mid-rectus incision was empIoyed and found very satisfactory for stones near the bIadder. However, we beIieve the obIique incision affords an easier approach in the Iarger number of cases. The stones were found and removed in a11 but 2 instances. In one of these the caIcuIus sIipped back to the kidney, was not found in the renaI peIvis at this time, but was removed from the ureter at a Iater date. The other faiIure concerned one side of a patient in aImost complete anuria from doubIe uretera caIcuIi. We had one experience of faiIure to secure a stone Iow in the ureter, but opened the bIadder at once

490

American JournaI of Surgery

and obtained it from the intramura1 portion. UreteraI stones sometimes change position markedIy without causing pain. Hence we uniformIy require that a confirmatory roentgenogram be made just prior to operation. At operation, ureteral caIcuIi do not easily move down the ureter, but may readiIy sIip up toward the kidney. It is a usefu1 procedure to dissect above the stone as earIy as possibIe and pIace a tape under the ureter above the stone. As stated earIier, we pIace sutures in the ureter only in instances of Iong incisions. Adequate drainage is obviousIy necessary. Our preference for spina anesthesia has aIready been stated, and it has been empIoyed with great satisfaction in these cases for nearIy two years. Wounds: Two cases had no Ieakage of urine from the wounds. The others Ieaked for varying periods up to twenty-six days. If Ieakage continues after ten to fourteen days, a catheter is passed up the ureter and aIIowed to remain for a day or two. Stay in Hospital: In this group of 22 operations for uretera caIcuIus, there were no deaths. Three (I 4 per cent) went home in eighteen days after operation; I I (50 per cent) in twenty to twenty-nine days; 8 (36 per cent) in thirty to forty days. The Iast group represents chieffy badIy infected wounds, the infection having been present in the corresponding kidney before operation. One patient had probabIe femoral thrombosis, but was discharged on the thirty-sixth day. One case with postoperative epididymitis was discharged on the thirty-second day. ApparentIy, patients stay in the hospita1 Ionger after uretera operations than after kidney operations for caIcuIus. BILATERAL

SEPTEMBER. rgzj0

Stevens and CoIIings-CaIeuIus

CALCULUS

The problem of biIatera1 calcuIus disease of the upper urinary tract has often been discussed. The usua1 advice is to operate first on the side having the better kidney. But some wiI1 decide this question on the

basis of the comparative function tests of the kidneys as found before operation. This may be very misIeading. The better kidney may be functioning badIy for the time being, because of uretera obstruction. It is necessary to consider the position of the caIcuIi and to note the possibiIities of obstruction, as this factor is the most potent one for immediate harm. Hence our feeIing is that each case presents a probIem unto itseIf. Having studied the patient, the cystoscopic and functiona reports, and the roentgenograms, we advise operation first on that stone, the remova of which wiI1 enhance the tota renaI function the most. CALCULUS

ANURIA

There are differences of opinion concerning methods of treating patients with complete bIockage of one or both ureters. ProIonged tria1 of paIIiative measures is to be condemned. The patient shouId be pIaced in a hospita1 where operation can be performed at a moment’s notice. Cystoscopic methods wiI1 often reIieve the obstruction, at Ieast temporarily, wiI1 thus aIIow time for further study, and wiI1 put the patient in better condition should operation become necessary. Furthermore, in some instances, a ffow of urine wiI1 become estabIished, after the uretera catheters have been removed, and the patient may uItimateIy pass the stone, if smaI1. Continuous observation is urgentIy required, with frequent estimations of renal function. If this decreases, or the anuria recurs after the remova of the uretera catheters, immediate operation is imperative. If the condition remains good, but the stone does not move, operation wiI1 probabIy be indicated, but the emergency has passed. INDICATIONS

FOR

OPERATION

We wish, in cIosing, to consider briefly which stones in the kidney and ureter shouId be operated upon, and which shouId be Ieft aIone. As in a11 reaIms of surgery, one must fairly consider whether

NEW SERIFS VOL. 1X. No. 3

Stevens

and CoIIings-CaIcuIus

the probabIe benefit to foIIow operation wiI1 compensate for the possibIe harm and risk. Operation is usuaIIy indicated on kidney stones associated with reduced renaI function; coincident infection increases this demand. The chances of eIiminating infection accompanying stone without remova of that stone is sIight. The stone shouId be removed through a pyeIotomy incision if it seems feasibIe to do so. If the stone is smaI1 and so pIaced in the caIyx that nephrotomy wiI1 be required, it may be questioned whether such an operation wiII*not do more harm than good. Either persistent pain or hematuria is an indicaSiIent stones without tion for operation. infection, hematuria, pain, or diminished renaI function, we think shouId be Ieft aIone. As for uretera caIcuIi, we agree with the genera1 view that a11 these stones should be uItimateIy removed, and that stones casting shadows I cm. or more in diameter wiI1 probabIy require operation. We have had patients pass such Iarge stones, but this is not the ruIe. SmaIIer stones can usuaIIy be made to come away by cystoscopic manipuIations. There is danger in proIonging these efforts; irreparabIe function damage may ensue. Diminished of the kidney, especiaIIy decreasing function and most particuIarIy anuria, demand an earIy operation. SUMMARY

data concerning 70 I. We present patients operated upon at BeIIevue Hospital for caIcuIus disease of the upper eB+

American Joud

of surgery

491

urinary tract; these represent 51 kidney operations and 22 uretera operations. 2. The vast majority of our patients come to the hospita1 for the reIief of renaI pain. 3. Kidney and uretera stones usuaIIy decrease the renaI function, and increase any existing infection. 4. Spinai anesthesia has been used with in the more recent great satisfaction operations. 5. PyeIotomy is the operation of choice for kidney stones; a pyelonephrotomy or a nephrectomy may be necessary. 6. OnIy the Iarger pyeIotomy and ureterotomy incisions are sutured after the remova of the stone. 7. FoIIowing the 5 I operations for stones in the kidney, there were 8 deaths, most of which occurred in desperateIy III patients with troubIe of Iong standing and with demanding operative relief. symptoms There were no deaths foIIowing the 22 uretera operations. 8. A curved Ioin incision is used for kidney and upper ureter stones; the obIique Gibson incision for Iower ureter stones. g. In cases of biIatera1 caIcuIi, as a genera1 ruIe operate first upon the stone, the remova of which wiI1 most markedIy enhance the tota renaI function. IO. Indications for operation are, diminishing function, increasing infection, uretera stone over I cm. in anuria, diameter, persistent pain, and recurring hematuria. I I. AI1 uretera stones shouId be uItimateIy removed by cystoscopic manipuIations preferably, or by operation.